state plan under title xix of the social security …dhhs.ne.gov/documents/medicaid state plan part...

STATE PLAN UNDER TITLE XIX

OF THE SOCIAL SECURITY ACT

MEDICAL ASSISTANCE PROGRAM

.

HCFA-AT-80-38 (BPP)

May 22, 1980

Revision: HCFA-PM-87-4 (BERC) OMB No. 0938-0193 March 1987

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT Nebraska Medical Assistance Program

State/Territory: Nebraska

TABLE OF CONTENTS SECTION PAGE NUMBERS

State Plan Submittal Statement ........................................................................ 1 SECTION 1 - SINGLE STATE AGENCY ORGANIZATION ............................... 2

1.1 Designation and Authority ..................................................................... 2

1.2 Organization for Administration ............................................................. 7

1.3 Statewide Operation .............................................................................. 8

1.4 State Medical Care Advisory Committee ............................................... 9

i

TN No. MS-87-11 Supersedes Approval Date Aug 6 1987 Effective Date Apr 1 1987

Transmittal No. N/A HCFA ID : 1002P/0010P


SECTION PAGE NUMBERS SECTION 2 - COVERAGE AND ELIGIBILITY..................................................... 10

2.1 Application, Determination of Eligibility and Furnishing Medicaid ........................................................................ 10

2.2 Coverage and Conditions of Eligibility.................................................... 12

2.3 Residence .............................................................................................. 13 2.4 Blindness................................................................................................ 14 2.5 Disability ................................................................................................. 15 2.6 Financial Eligibility .................................................................................. 16 2.7 Medicaid Furnished Out of State............................................................ 18

ii



Revision: HCFA-PM-87-4 (BERC) OMB No. 0938-0193 March 1987 SECTION PAGE NUMBERS SECTION 3 - SERVICES: GENERAL PROVISIONS .......................................... 19

3.1 Amount, Duration, and Scope of Services ............................................. 19

3.2 Coordination of Medicaid with Medicare Part B ..................................... 29

3.3 Medicaid for Individuals Age 65 or Over in Institutions for Mental Diseases.......................................................... 30 3.4 Special Requirements Applicable to Sterilization Procedures ......................................................................... 31 3.5 Medicaid for Medicare Cost Sharing for

Qualified Medicare Beneficiaries........................................................... 31a 3.6 Ambulatory Prenatal Care for Pregnant Women during Presumptive Eligibility Period..................................................... 31b

iii



Revision: HCFA-PM-87-4 (BERC) OMB No. 0938-0193 March 1987 SECTION PAGE NUMBERS SECTION 4 -GENERAL PROGRAM ADMINISTRATION ................................................ 32

4.1 Methods of Administration ................................................................................. 32

4.2 Hearings for Applicants and Recipients............................................................. 33

4.3 Safeguarding Information on Applicants and Recipients ................................................................................................... 34 4.4 Medicaid Quality Control.................................................................................... 35 4.5 Medicaid Agency Fraud Detection and Investigation Program........................................................................................ 36 4.6 Reports .............................................................................................................. 37 4.7 Maintenance of Records.................................................................................... 38 4.8 Availability of Agency Program Manuals ........................................................... 39

4.9 Reporting Provider Payments to the Internal Revenue Service .................................................................................. 40

4.10 Free Choice of Providers ................................................................................... 41

4.11 Relations with Standard-Setting and Survey Agencies......................................................................................... 42

4.12 Consultation to Medical Facilities ...................................................................... 44

4.13 Required Provider Agreement ........................................................................... 45 4.14 Utilization/Quality Control .................................................................................. 46

4.15 Inspection of Care in Skilled Nursing and Intermediate Care Facilities and Institutions for Mental Disease........................................................................... 51

4.16 Relations with State Health and Vocational Rehabilitation Agencies and Title V Grantees ................................................... 52

4.17 Liens and Adjustments or Recoveries ............................................................... 53

4.18 Cost Sharing and Similar Charges .................................................................... 54

4.19 Payment for Services......................................................................................... 57

iv



Revision: HCFA-PM-90-2 (BPD) OMB No. 0938-0193 January 1990 SECTION PAGE NUMBERS

4.20 Direct Payments to Certain Recipients for Physicians’ or Dentists’ Services ................................................................ 67

4.21 Prohibition Against Reassignment of Provider Claims........................................................................................... 68 4.22 Third Party Liability ..................................................................................... 69 4.23 Use of Contracts ......................................................................................... 71 4.24 Standards for Payments for Skilled Nursing and Intermediate Care Facility Services ..................................................... 72 4.25 Program for Licensing Administrators of Nursing Homes ....................................................................................... 73 4.26 RESERVED ................................................................................................ 74

4.27 Disclosure of Survey Information and Provider or Contractor Evaluation ........................................................ 75

4.28 Appeals Process for Skilled Nursing and Intermediate Care Facilities ................................................................. 76

4.29 Conflict of Interest Provisions ..................................................................... 77

4.30 Exclusion of Providers and Suspension of Practitioners Convicted and Other Individuals ............................................ 78

4.31 Disclosure of Information by Providers and Fiscal Agents ....................................................................................... 79

4.32 Income and Eligibility Verification System................................................... 79

4.33 Medicaid Eligibility Cards for Homeless Individuals............................................................................. 79a

4.34 Systematic Alien Verification for Entitlements............................................. 79b

4.35 Remedies for Skilled Nursing and Intermediate Care Facilities that Do Not Meet Requirements of Participation..................................................................... 79c

v


Transmittal No. MS-87-11 HCFA ID: 1002P/0010P


SECTION PAGE NUMBERS

SECTION 5 - PERSONNEL ADMINISTRATION ................................................. 80

5.1 Standards of Personnel Administration .................................................. 80

5.2 RESERVED ........................................................................................... 81

5.3 Training Programs; Subprofessional and Volunteer Programs ............................................................................... 82

vi


Transmittal No. N/A HCFA ID: 1002P/0010P


SECTION PAGE NUMBERS SECTION 6 - FINANCIAL ADMINISTRATION .................................................... 83

6.1 Fiscal Policies and Accountability .......................................................... 83

6.2 Cost Allocation ....................................................................................... 84

6.3 State Financial Participation................................................................... 85

vii


Transmittal No. N/A HCFA ID: 1002P/0010P

Revision: HCFA-PM-91-4 (BERC) OMB No. 0938- August 1991 State/Territory: Nebraska

SECTION PAGE NUMBERS SECTION 7 - GENERAL PROVISIONS............................................................... 86

7.1 Plan Amendments .................................................................................. 86

7.2 Nondiscrimination................................................................................... 87

7.3 Maintenance of AFDC Effort .................................................................. 88 7.4 State Governor’s Review........................................................................ 89

viii

TN No. MS-91-24 Supersedes Approval Date Jan 20 1992 Effective Date Nov 1 1991

Transmittal No. MS-87-11 HCFA ID: 1002P/0010P

Revision: HCFA-PM-91-4 (BPD) OMB No. 0938- August 1991

LIST OF ATTACHMENTS No. Title of Attachment *1.1-A Attorney General’s Certification *1.1-B Waiver(s) Under the Intergovernmental Cooperation Act 1.2-A Organization and Functions of the Medicaid Agency 1.2-B Organization and Function of the Medical Assistance Unit 1.2-C Professional Medical and Supporting Staff 1.2-D Description of Staff Making Eligibility Determination *2.2-A Groups Covered and Agencies Responsible for Eligibility Determinations * Supplement 1 – Reasonable Classifications of Individuals under the Age of 21, 20, 19 and 18 * Supplement 2 – Definitions of Blindness and Disability (Territories only) * Supplement 3 – Method of Determining Cost Effectiveness of Caring for Certain Disabled Children at Home *2.6-A Eligibility Conditions and Requirements (States only) * Supplement 1 - Income Eligibility Levels – Categorically Needy, Medically Needy and Qualified Medicare Beneficaries * Supplement 2 - Resource Levels - Categorically Needy, Including Groups with Income Up to a Percentage of the Federal Proverty Level, Medically Needy, and Other Optional Groups * Supplement 3 - Reasonable Limits on Amounts for Necessary Medical or Remedial Care Not Covered Under Medicaid * Supplement 4 - Section 1902(f) Methodologies for Treatment of Income that Differ from Those of the SSI Program * Forms Provided

TN No. MS-03-12 Supersedes Approval Date Nov 6, 2003 Effective Date Aug 13, 2003

Transmittal No. MS-91-24

Revision: HCFA-PM-91-5 (MB) OMB No. October 1991 Page 2 No. Title of Attachment * Supplement 5 - Section 1902(f) Methodologies for Treatment of Resources that Differ from Those of the SSI Program * Supplement 5a - Methodologies for Treatment of Resources for Individuals With Incomes Up to a Percentage of the Federal Poverty Level * Supplement 6 - Standards for Optional State Supplementary Payments * Supplement 7 - Income Levels for 1902(f) States – Categorically Needy Whoare Covered under Requirements More Restrictive Than SSI * Supplement 8 - Resource Standards for 1902(f) States – Categorically Needy * Supplement 8a - More Liberal Methods of Treating Income Under Section 1902(r)(2) of the Act * Supplement 8b - More Liberal Methods of Treating Resources Under Section 1902(r)(2) of the Act * Supplement 9 - Transfer of Resources * Supplement 10 - Consideration of Medicaid Qualifying Trusts- Undue Hardship * Supplement 11 - Cost - Effective Methods for COBRA Groups (States and Territories) *2.6-A Eligibility Conditions and Requirements (Territories only) * Supplement 1 - Income Eligibility Levels – Categorically Needy, Medically Needy and Qualified Medicare Beneficaries * Supplement 2 - Resource Levels on Amounts for Necessary Medical or Remedial Care Not Covered Under Medicaid * Supplement 3 - Resource Levels for Optional Groups with Incomes Up to a Percentage of the Federal Poverty Level and Medically Need. * Supplement 4 - Consideration of Medicaid Qualifying Trusts - Undue Hardship * Supplement 5 - More Liberal Methods of Treating Income under Section 1902(r)(2) of the Act * Supplement 6 - More Liberal Methods of Treating Resources under Section 1902(r)(2) of the Act * Forms Provided

TN No. MS-91-29 Supersedes Approval Date Jan 15 1992 Effective Date Oct 1 1991


Revision: HCFA-PM-91-4 (BPD) OMB No. 0938- August 1991 Page 3 State/Territory: Nebraska No. Title of Attachment *3.1-A Amount, Duration, and Scope of Medical and Remedial Care and Services Provided to the Categorically Needy * Supplement 1 - Case Management Services * Supplement 2 - Alternative Health Care Plans for Families Covered Under Section 1925 of the Act *3.1-B Amount, Duration, and Scope of Services Provided Medically Needy Groups 3.1-C Standards and Methods of Assuring High Quality Care 3.1-D Methods of Providing Transportation *3.1-E Standards for the Coverage of Organ Transplant Services 3.1-F Definition of MCO, PCCM 4.11-A Standards for Institutions 4.14-A Single Utilization Review Methods for Intermediate Care Facilities 4.14-B Multiple Utilization Review Methods for Intermediate Care Facilities 4.16-A Cooperative Arrangements with State Health and State Vocational Rehabilitation Agencies and with Title V Grantees 4.17-A Determining that an Institutionalized Individual Cannot Be Discharged and Returned Home *4.18-A Charges Imposed on Categorically Needy *4.18-B Medically Needy - Premium *4.18-C Charges Imposed on Medically Needy and Other Optional Groups *4.18-D Premiums Imposed on Low Income Pregnant Women and Infants *4.18-E Premiums Imposed on Qualified Disabled and Working Individuals 4.19-A Methods and Standards for Establishing Payment Rates – Inpatient Hospital Care * Forms Provided

TN No. MS-03-12 Supersedes Approval Date Nov 6, 2003 Effective Date Aug 13, 2003


Revision: HCFA-PM-91-8 (MB) OMB No.: October 1991 Page 4 State/Territory: Nebraska No. Title of Attachment 4.19-B Methods and Standards for Establishing Payment Rates – Other Types of Care * Supplement 1 - Methods and Standards for Establishing Payment Rates for Title XVIII Deductible/Coinsurance 4.19-C Payments for Reserved Beds 4.19-D Methods and Standards for Establishing Payment Rates – Skilled Nursing and Intermediate Care Facility Services 4.19-E Timely-Claims Payment - Definition of Claim 4.20-A Conditions for Direct Payment for Physicians’ and Dentists’ Services 4.22-A Requirements for Third Party Liability - Identifying Liable Resources *4.22-B Requirements for Third Party Liability - Payment of Claims *4-22-C Cost-Effective Methods of Employer-Based Group Health Plans *4.32-A Income and Eligibility Verification System Procedures: Requests to Other State Agencies *4.33-A Method for Issuance of Medicaid Eligibility Cards to Homeless Individuals 7.2-A Methods of Administration - Civil Rights (Title VI) *Forms Provided


Transmittal No. MS-91-24 HCFA ID: 7982E

Revision: HCFA-PM-91-4 (BPD) OMB No. 0938- August 1991

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURTIY ACT MEDICAL ASSISTANCE PROGRAM

State/Territory: Nebraska Citation As a condition for receipt of Federal funds under the title XIX of the Social Security Act the 42 CFR 430.10 Nebraska Department of Health and Human Services (Single State Agency)

submits the following State plan for the medical assistance program, and hereby agrees to administer the program in accordance with the provisions of this State plan, the requirement of titles XI and XIX of the Act, and all applicable Federal regulations and other official issuances of the Department.

TN No. MS-07-05 Supersedes Approval Date Nov 29 2007 Effective Date Jul 1 2007 TN No. MS-97-6

Revision: HCFA AT-80-38 (BPP) OMB No.: 0938-0193 May 22, 1980


SECTION 1 - SINGLE STATE AGENCY ORGANIZATION Citation 1.1 Designation and Authority 42 CFR 431.10 (a) The Nebraska Department of Health and Human AT-79-29 Services is the single State agency designated to

administer or supervise the administration of the Medicaid program under title XIX of the Social Security Act. (All references In this plan to "the Medicaid agency" mean the agency named in this paragraph.)

ATTACHMENT 1.1-A, is a certification signed by the State Attorney General identifying the single State agency and citing the legal authority under which It administers or supervises administration of the program

TN No. MS-07-05 Supersedes Approval Date Nov 29 2007 Effective Date Jul 01 2007

TN No. MS-97-6

3

Revision: HCFA-AT-80-38 (BPP) May 22, 1980 State/Territory: Nebraska Citation Sec. 1902 1.1(b) The State agency that administered or supervised (a)of the Act the administration of the plan approved under title X of the Act as of January 1, 1965, has been separately designated to administer or supervise the administration of that part of this plan which relates to blind individuals.

Yes. The State agency so designated is This agency has a separate plan covering that portion

of the State plan under title XIX for which it is responsible.

Not applicable. The entire plan under title XIX is administered or supervised by the State agency named in paragraph 1.1(a).

TN No. MS-76-13 Supersedes Approval Date Dec 13 1976 Effective Date Dec 1 1976

TN No. MS-75-1

4 Revision: HCFA-AT-80-38 (BPP) May 22, 1980 State/Territory: Nebraska Citation

1.1(c) Waivers of the single State agency requirement which are currently operative have been granted under authority of the Intergovernmental Cooperation Act of 1968.

Yes. ATTACHMENT 1.1-B describes these waivers and the approved alternative organizational arrangements.

Not applicable. Waivers are no longer in effect.

Not applicable. No waivers have ever been granted.


TN No. MS-75-1

5

Revision: HCFA-AT-80-38 (BPP) OMB No. 0938-0193 May 22, 1980 State/Territory: Nebraska Citation

42 CFR 431.10 1.1(d) The agency named in paragraph 1.1(a) AT-79-29 has responsibility for all determinations of eligibility for Medicaid under this plan.

Determinations of eligibility for Medicaid

under this plan are made by the agency(ies) specified in ATTACHMENT 2.2-A. There is a written agreement between the agency named in paragraph 1.1(a) and other agency(ies) making such determinations for specific groups covered under this plan. The agreement defines the relationships and respective responsibilities of the agencies.


TN No. MS-75-1


1.1(e) All other provisions of this plan are administered by 42 CFR 431.10 the Medicaid agency except for those functions for AT-79-29 which final authority has been granted to a

Professional Standards Review Organization under title XI of the Act.

(f) All other requirements of 42 CFR 431.10 are met.


TN No. MS-75-1

7 Revision: HCFA-AT-80-38 (BPP) OMB No. 0938-0193 May 22, 1980 State/Territory: Nebraska Citation

1.2 Organization for Administration 42 CFR 431.11 (a) ATTACHMENT 1.2-A contains a description of the AT-79-29 organization and functions of the Medicaid agency and an organization of the agency.

(b) Within the State agency, the Division of Medicaid &

Long-Term Care has been designated as the medical assistance unit. ATTACHMENT 1.2-B contains a description of the organization and functions of the medical assistance unit and an organization chart of the unit.

(c) ATTACHMENT 1.2-C contains a description of the

kinds and numbers of professional medical personnel and supporting staff used in the administration of the plan and their responsibilities.

(d) Eligibility determinations are made by State or local

staff of an agency other than the agency named in paragraph 1.1(a). ATTACHMENT 1.2-D contains a description of the staff designated to make such determinations and the functions they will perform.

Not applicable. Only staff of the agency

named in paragraph 1.1(a) make such determinations.


TN No. MS-97-6

8 Revision: HCFA-AT-80-38 (BPP) May 22, 1980 State/Territory: Nebraska Citation 1.3 Statewide Operation 42 CFR The plan is in operation on a Statewide basis in accordance 431.50(b) with all requirements of 42 CFR 431.50. AT-79-29

The plan is State administered.

The plan is administered by the political subdivisions of the State and is mandatory on them.

TN No. MS-83-17 Supersedes Approval Date Sept 26 1983 Effective Date Aug 26 1983

TN No. MS-74-10

9

Approved OMB#: 0938-1098

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State:

Nebraska

1.4 State Medical Care Advisory CommitteeThere is an advisory committee to the Medicaid agency director on health and medical care

(42 CFR 431.12(b))

services established in accordance with and meeting all the requirements of 42 CFR 431.12.

_X_

consult with the Medical Care Advisory Committee in the review of

The State enrolls recipients in MCO, PIHP, PAHP, and/or PCCM programs. The State assures that it complies with 42 CFR 438.104(c) to

marketing materials.

Section 1902(a)(73) of the Social Security Act (the Act) requires a State in which one or more Indian Health Programs or Urban Indian Organizations furnish health care services to establish a process for the State Medicaid agency to seek advice on a regular, ongoing basis from designees of Indian health programs, whether operated by the Indian Health Service (IHS), Tribes or Tribal organizations under the Indian Self-Determination and Education Assistance Act (ISDEAA), or Urban Indian Organizations under the Indian Health Care Improvement Act (IHCIA). Section 2107(e)(I) of the Act was also amended to apply these requirements to the Children’s Health Insurance Program (CHIP). Consultation is required concerning Medicaid and CHIP matters having a direct impact on Indian health programs and Urban Indian organizations.

Tribal Consultation Requirements

Please describe the process the State uses to seek advice on a regular, ongoing basis from federally-recognized tribes, Indian Health Programs and Urban Indian Organizations on matters related to Medicaid and CHIP programs and for consultation on State Plan Amendments, waiver proposals, waiver extensions, waiver amendments, waiver renewals and proposals for demonstration projects prior to submission to CMS. Please include information about the frequency, inclusiveness and process for seeking such advice.

The Division of Medicaid and Long-Term Care (MLTC) meets on a quarterly basis or as needed with the tribes (Omaha, Ponca, Santee Sioux and Winnebago) and with the CMS Native American contact to discuss relevant Medicaid/CHIP matters that impact the tribes and to invite discussion and comments for consideration. Effective September 1, 2010, MLTC implemented a policy regarding seeking consultation from all federally recognized tribes, Indian Health Service and Urban Indian Organizations within the state regarding State Plan Amendments (SPA), proposals for demonstrations, and waivers, including proposed, extensions, amendments and renewals,

____________________________________________________________________________ TN No: Supersedes Approval Date

11-15 OCT 13 2011 Effective Date

TN No. JUL 01 2011

MS 03-12

9.1 (1.4 continued)

which may have an impact on those entities. All proposed SPA’s, waivers, and demonstrations will be sent to the Tribes for comment, not just those that we believe will directly impact the tribes. However, purely technical changes that have no impact on the substance of the topic (such as pagination, renumbering of lists, etc.) will not be submitted to the Tribes. Proposed SPA’s, waivers, and demonstrations are routed to the tribes for comment/input prior to submitting to CMS. The Division of Medicaid and Long-Term Care consults with the tribes by notifying designated tribal entities electronically via email with a description of the proposed change(s). The tribal liaison, which is a position designated by the Division of Medicaid and Long-Term Care, is responsible for maintaining a complete list of tribal contacts and their respective email and mailing addresses. The tribal contact list is updated at the tribal consultation meetings and was last updated at the tribal consultation meeting held in November, 2010. The proposed SPA, waiver, or demonstration is submitted to Tribal Clinics, Health Centers, the IHS Hospital, and to the Nebraska Urban Ian Health Coalition for comment. The tribes have 30 days to respond or comment to the proposed SPA, waiver or demonstration from the date the required notice is submitted to the tribes. Following the 30 day period, if no comment is received from the tribes, the Division of Medicaid and Long-Term Care is authorized to submit the SPA, waiver or demonstration to CMS. The CMS Native American Contact is copied in this process by the MLTC to detail our efforts to secure comments/input from the Tribes. If comments are, in fact, received from the tribes, the same is relayed to the Division Director for further consideration. In situations where comments are received from the tribes, the consultation process time-frame shall extend to a 60 day time period from the date the required notice was submitted to the tribes so that the Division of Medicaid and Long-Term Care can address such comments as set forth below. Following the 60 day period after comments are received from the tribes, the Division of Medicaid and Long-Term Care is authorized to submit the SPA, waiver or demonstration to CMS. If one tribe has a question or concern about a SPA, waiver amendment, waiver extension, waiver renewal or demonstration proposal, that concern would be communicated and transmitted electronically via e-mail to all other tribes and tribal entities by the tribal liaison. Such communication will specify who raised the concern or comment, the specific nature of the concern or comment, and what the Department proposed to do in response to that concern or comment in an attempt to address or resolve the concern. A management decision is then made as to whether additional action (telephone conferences, meetings, research, etc.) would be appropriate under the circumstances prior to submitting the SPA, waiver or demonstration to CMS. Comments from the Tribes, or the lack of comments/response, are reported to the CMS Native American Contact, as well as our response/resolution to those comments.

_______________________________________________________________________ TN No: Supersedes Approval Date

11-30 DEC 16 2011 Effective Date

TN No. NOV 01 2011

11-15

9.2

(1.4 continued)

The consultation process established by the Department is based in part on face to face visits and discussions with various tribal entities and the Nebraska Department of Health and Human Services. At the November 29, 2010 meeting, discussions were initiated relating to the proposed SPA consultation process. Tribal Liaison shared the written policy of the Department as it existed at that time regarding the proposed consultation process. Comments from the tribes regarding the process and how it might impact the tribes were noted and later expressed to state Medicaid management. At the November meeting, it was proposed by the Department that the tribes be given notice regarding all proposed SPA’s and waivers, not just those that the Department thought might have some impact on the tribes. Some members expressed the Department should indicate to the tribes which SPA’s and waivers had a direct impact on the tribes in its opinion. The tribes also expressed that it would be helpful to have a process in place to share comments and Department responses to those comments during the consultation process. These suggestions were discussed with Medicaid administrators and adopted by the Department. Current policy is that if one tribe has a question or concern about a SPA or waiver, that concern will be made known to all the tribal entities by the Department, as well as making it known how the Department attempted to resolve the concern. In order to facilitate the consultation process, the Department will, in advance of the consultation meeting, provide the tribes with a formal agenda describing the SPA’s and waivers that might have relevance to the tribes, as well as other information that will be addressed by the Department. The Department will take minutes of the meeting, which will be available on request, and maintain a record of the same. The Department will ensure that a current roster of participants is kept and maintained, indicating participant’s names, addresses, telephone numbers, and with which group they are associated.

Please describe the consultation process that occurred specifically for the development and submission of this State Plan Amendment, when it occurred and who was involved.

In January of 2010, the State received guidance from CMS, SMDL# 10-001, that set forth the general requirements expected of States to alert tribal entities to proposed State Plan Amendments, waivers, and demonstrations. On February 18, 2010, a Nebraska State/Tribal Consultation Meeting was held. Attending were representatives from the various Tribes in Nebraska, Indian health providers, the Native American Contact from CMS, the Nebraska Medicaid tribal liaison, and the Nebraska Medicaid Director. The tribal consultation issue was discussed in general terms at the meeting and the Tribes expressed a desire to become involved in the consultation process.

Initial Amendment

______________________________________________________________________ TN No: Supersedes Approval Date


TN No. NOV 01 2011

11-15

9.3 (1.4 continued)

Following this, a written process was developed by Nebraska Medicaid outlining the process for the State to follow to secure consultation with the Tribes prior to the State submitting a SPA, waiver, or demonstration. The proposed process was reviewed and approved by Nebraska Medicaid administration. In June, 2010, the protocol for consultation was shared with Medicaid Division staff and sent to the tribal entities. In October 2010, the State received additional guidance from CMS regarding the consultation process required with tribal entities prior to submitting a SPA, waiver, or demonstration to CMS. The guidance suggested that states should submit to the Tribes a comprehensible summary of the effect of the proposed SPA, waiver, or demonstration rather than merely submitting the SPA, waiver, or demonstration documents. Nebraska Medicaid revised the protocol for submitting a SPA, waiver, or demonstration and securing tribal consultation and communicated to Medicaid Division staff. On November 2, 2010, the State notified all tribal entities its intent to submit a SPA regarding the tribal consultation process. The letter outlined a summary of the consultation process set forth in the revised protocol. The tribal consultation issue was discussed in detail at a November 29, 2010 Nebraska State/Tribal Consultation Meeting. Attending were representatives from the various Tribes in Nebraska, Indian health providers, the Native American Contact from CMS, and the Nebraska Medicaid tribal liaison. The tribal consultation issue was discussed in detail at the meeting.

A communication was sent to all tribal entities June 2, 2011, advising them of the

Prior Amendment

technical changes and it was also discussed at a meeting with them July 12, 2011.

Current Amendment

A communication was sent to all tribal entities September 7, 2011 advising them that the Department intended to submit a SPA to change the current consultation process, allowing the tribes 30 days to respond to proposed SPA’s, waivers or demonstrations and establishing a 60 day time-period for the consultation process if comments were received from the tribes. ___________________________________________________________________________________________ TN No: Supersedes Approval Date


TN No. NOV 01 2011

11-15

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1098. The time required to complete this information collection is estimated to average 1 hour per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. CMS-10293 (07/2013)

9a Revision: HCFA-PM-94-3 (MB) April 1994 State/Territory: Nebraska

Citation

1.5 Pediatric Immunization Program

1928 of 1. The State has implemented a program for the distribution of pediatric the Act vaccines to program- registered providers for the immunization of federally vaccine eligible children in accordance with section 1928 as indicated below.

a. The State program will provide each vaccine-eligible child with medically

appropriate vaccines according to the schedule developed by the Advisory Committee on Immunization Practices and without charge for the vaccines. b. The State will outreach and encourage a variety of providers to participate in

the program and to administer vaccines in multiple settings, e.g., private health care providers, providers that receive funds under Title V of the Indian Health Care Improvement Act, health programs or facilities operated by Indian tribes, and maintain a list of program- registered providers.

c. With respect to any population of vaccine- eligible children a substantial

portion of whose parents have limited ability to speak the English language, the State will identify program-registered providers who are able to communicate with this vaccine-eligible population in the language and cultural context which is most appropriate.

d. The State will instruct program-registered providers to determine eligibility in accordance with section 1928(b) and (h)of the Social Security

Act. e. The State will assure that no program- registered provider will charge more

for the administration of the vaccine than the regional maximum established by the Secretary. The State will inform program-registered providers of the maximum fee for the administration of vaccines.

f. The State will assure that no vaccine-eligible child is denied vaccines

because of an inability to pay an administration fee. g. Except as authorized under section 1915(b) of the Social Security Act or as

permitted by the Secretary to prevent fraud or abuse, the State will not impose any additional qualifications or conditions, in addition to those indicated above, in order for a provider to qualify as a program-registered provider.

TN No. MS-94-016 Supersedes Approval Date Mar 20 1995 Effective Date Oct 1 1994 TN No. New page

9b Revision: HCFA-PM-94-3 (MB) April 1994 State/Territory: Nebraska Citation

1928 of 2. The State has not modified or repealed any Immunization Law in the Act effect as of May 1, 1993 to reduce the amount of health insurance

coverage of pediatric vaccines. 3. The State Medicaid Agency has coordinated with the State Public Health Agency in the completion of this preprint page. 4. The State agency with overall responsibility for the Implementation and enforcement of the provisions of section 1928 is:

State Medicaid Agency

State Public Health Agency

TN No. MS-94-016 Supersedes Approval Date Mar 20 1995 Effective Date Oct 1 1994

TN No. New Page

10

Revision: HCFA-PM-91-4 (BPD) OMB No. 0938- August 1991 State/Territory: Nebraska SECTION 2 – COVERAGE AND ELIGIBILITY Citation

2.1 Application, Determination of Eligibility and Furnishing Medicaid 42 CFR (a) The Medicaid agency meets all requirements of 42 CFR Part 435, Part 435, Subpart J for processing applications, Subpart J determining eligibility, and furnishing Medicaid. TN No. MS-91-24 Supersedes Approval Date Jan 20 1992 Effective Date Nov 1 1991

TN No. MS-75-9 HCFA ID: 7982E

11 Revision: HCFA-PM-91-4 (BPP) OMB No. 0938- August 1991 State/Territory: Nebraska Citation

2.1 (b) (1) Except as provided in items 2.1(b)(2) and (3) below, individuals 42 CFR are entitled to Medicaid services under the plan during the three 435.914 months preceding the month of application, if they were, or on 1902(a) (34) application would have been, eligible. The effective date of of the Act prospective and retroactive eligibility is specified in Attachment 2.6-A. 1902(e)(8) and (2) For individuals who are eligible for Medicare cost- sharing 1905(a) of the expenses as qualified Medicare beneficiaries under section Act 1902(a)(10)(E)(i) of the Act, coverage is available for services

furnished after the end of the month which the individual is first determined to be a qualified Medicare beneficiary. Attachment 2.6-A specifies the requirements for determination of eligibility for this group.

1902(a)(47) and (3) Pregnant women are entitled to ambulatory prenatal care under the plan during a presumptive eligibility period in accordance with section 1920 of the Act. Attachment 2.6-A specifies the requirements for determination of eligibility for this group.

42 CFR (c) The Medicaid agency elects to enter into a risk contract that 438.6 complies with 42 CFR 438.6, and that is procured through an open, competitive procurement process that is consistent with 45 CFR Part 74. The risk contract is with (check all that apply):

Qualified under Title XIII 1310 of the Public Health Service Act.

A Managed Care Organization that meets the definition of 1903(m) of the Act and 42 CFR 438.2.

A Prepaid Inpatient Health Plan that meets the definition of

42 CFR 438.2.

A Prepaid Ambulatory Health Plan that meets the definition of 42 CFR 438.2.

Not applicable.

TN No. MS-03-12 Supersedes Approval Date Nov 6 2003 Effective Date Aug 13 2003

TN No. MS-91-24

substitute per letter dated 12/18/91 11a Revision: HCFA-PM-91-6 (MB) OMB No.: September 1991 State/Territory: Nebraska Citation 2.1 (d) The Medicaid agency has procedures to take 1902(a)(55) applications, assist applicants, and perform initial of the Act processing of applications from those low income pregnant women, infants, and children under age 19,

described is §1902(a)(10)(A)(i)(IV), (a)(10) (A)(i) (VI), (a)(10)(A)(i)(VII), and (a)(10)(A)(ii)(IX) at locations other than those used by the title IV-A program including FQHCs and disproportionate share hospitals. Such application forms do not include the ADFC form except as permitted by HCFA instructions.

Note: Applications may be taken for all eligibility groups.

TN No. MS-91-22 Supersedes Approval Date Dec 20 1991 Effective Date July 1 1991

TN No. New Page HCFA ID: 7982E

12 Revision: HCFA-PM-91-4 (BPD) OMB No. 0938 August 1991 State/Territory: Nebraska Citation

2.2 Coverage and Conditions of Eligibility 42 CFR Medicaid is available to the groups specified in ATTACHMENT 2.2-A. 435.10

Mandatory categorically needy and other required special groups only.

Mandatory categorically needy, other required special groups, and the medically needy, but no other optional groups.

Mandatory categorically needy, other required special groups, and specified optional groups.

Mandatory categorically needy, other required special groups, specified optional groups, and the medically needy.

The conditions of eligibility that must be met are specified in ATTACHMENT 2.6-A.

All applicable requirements of 42 CFR Part 435 and sections 1902(a)(10)(A)(i)(IV), (V), and (VI), 1902(a)(10)(A)(ii)(XI), 1902(a)(10)(E), 1902(1) and (m), 1905(p), (q) and (s), 1920, and 1925 of the Act are met.



13 Revision: HCFA-PM-87-4 (BERC) OMB No. 0938-0193 March 1987 State/Territory: Nebraska Citation 2.3 Residence 435.10 and Medicaid is furnished to eligible individuals who are residents 435.403, and of the State under 42 CFR 435.403, regardless of whether or 1902(b) of the not the individuals maintain the residence permanently or Act, P.L. 99- maintain it at a fixed address. 272 (Section 9529)and P.L. 99-509 (Section 9405) TN No. MS-87-11 Supersedes Approval Date Aug 6 1987 Effective Date Apr 1 1987

TN No. MS-86-25

14 Revision: HCFA-PM-87-4 (BERC) OMB No. 0938-0193 March 1987 State/Territory: Nebraska Citation 2.4 Blindness 42 CFR All of the requirements of 42 CFR 435.530 and 42 CFR 435.530(b) 435.531are met. The more restrictive definition of blindness in 42 CFR terms of ophthalmic measurement used in this plan is 435.531 specified in ATTACHMENT 2.2-A. AT-78-90 AT-79-29 TN No. MS-87-11 Supersedes Approval Date Aug 6 1987 Effective Date Apr 1 1987

TN No. MS-75-7 HCFA ID: 1006P/0010P

15 Revision: HCFA-PM-91- (BPD) OMB No. 0938- September 1991 State/Territory: Nebraska Citation 2.5 Disability 42 CFR All of the requirements of 42 CFR 435.540 and 435.541 are met. 435.121, The State uses the same definition of disability used under the 435.540(b) SSI program unless a more restrictive definition of disability 435.541 is specified in Item A.13.b. of ATTACHMENT 2.2-A of this plan. TN No. MS-92-1 Supersedes Approval Date Apr 10 1992 Effective Date Nov 1 1991

TN No. MS-91-24

16-17

Revision: HCFA-PM-92-1 (BPP) February 1992 State/Territory: Nebraska Citation 2.6 Financial Eligibility 42 CFR (a) The financial eligibility conditions for Medicaid-only 435.10 and eligibility groups and for persons deemed to be cash Subparts G & H assistance recipients are described in ATTACHMENT 1902(a)(10)(A)(i) 2.6- A. (III), (IV), (V), (VI), and (VII), 1902(a)(10)(A)(ii) (IX), 1902(a)(10) (A)(ii)(X), 1902 (a)(10)(C), 1902(f), 1902(1) and (m), 1905(p) and (s), 1902(r)(2), and 1920 TN No. MS-92-3 Supersedes Approval Date Apr 8 1992 Effective Date Jan 1 1992

TN No. MS-91-24

18

Revision: HCFA-PM-86-20 (BERC) OMB-No. 0938-0193 September 1986

State/Territory:

Nebraska

Citation

2.7

Medicaid Furnished Out of State

431.52 and Medicaid is furnished under the conditions specified in 42 CFR 1902(b) of 431.52 to an eligible individual who is a resident of the State the Act, P.L. while the individual is in another State, to the same extent 99-272 that Medicaid is furnished to residents in the State. (Section 9529) TN No. Supersedes Approval Date

MS-86-25 Jan 7 1987 Effective Date

TN No.

Oct 1 1986

MS-82-14 HCFA ID: 0053C/0061E

19 Revision: HCFA-PM-94-5 (MB) OMB No. 0938-0193 April 1994 State/Territory: Nebraska

SECTION 3 – SERVICES: GENERAL PROVISIONS Citation 3.1 Amount, Duration, and Scope of Services 42 CFR (a) Medicaid is provided in accordance with the requirements of Part 440, 42 CFR Part 440, Subpart B and sections 1902(a), 1902(e), Subpart B 1905(a), 1905(p), 1915, 1920, and 1925 of the Act. 1902(a), 1902(e), 1905(a), 1905(p), (1) Categorically needy. 1915, 1920, and 1925 of the Act Services for the categorically needy are described below and in ATTACHMENT 3.1-A. These services include:

(i) Each item or service listed in section 1905(a)(1)

through (5) and (21) of the Act, is provided as defined in 42 CFR Part 440, Subpart A, or, for EPSDT services, section 1905(r) and 42 CFR Part 441, Subpart B.

(ii) Nurse-midwife services listed in section

1905(a)(17) of the Act, are provided to the extent that nurse-midwives are authorized to practice under State law or regulation and without regard to whether the services are furnished in the area of management of the care of mothers and babies throughout the maternity cycle. Nurse-midwives are permitted to enter into independent provider agreements with the Medicaid agency without regard to whether the nurse-midwife is under the supervision of, or associated with, a physician or other health care provider.

Not applicable. Nurse-midwives are not

authorized to practice in this State. TN No. MS-94-07 Supersedes Approval Date Jul 13 1994 Effective Date Apr 1 1994

TN No. MS-91-24

19a Revision: HCFA-PM-91-4 (BPD) OMB No. 0938- August 1991 State/Territory: Nebraska Citation

3.1(a)(1) Amount, Duration, and Scope of Services: Categorically Needy (Continued) 1902(e)(5) of (iii) Pregnancy-related, including family planning the Act services, and postpartum services for a 60-day

period (beginning on the day pregnancy ends)and any remaining days in the month in which the 60th day falls are provided to women who, while pregnant, were eligible for, applied for, and received medical assistance on the day the pregnancy ends.

(iv) Services for medical conditions that may complicate

the pregnancy (other than pregnancy-related or postpartum services) are provided to pregnant women.

1902(a)(10), (v) Services related to pregnancy (including Clause (VII) prenatal, delivery, postpartum, and family of the matter planning services) and to other conditions that following (F) may complicate pregnancy are the same services of the Act provided to poverty level pregnant women eligible

under the provision of sections 1902(a)(10)(A)(i)(IV) and 1902(a)(10)(A)(ii)(IX) of the Act.



19b Revision: HCFA-AT-92-7 (MB) October 1992 State/Territory: Nebraska Citation

3.1(a)(1) Amount, Duration, and Scope of Services: Categorically Needy (Continued)

1902(a)(10)(D) (vi) Home health services are provided to of the Act individuals entitled to nursing facility services as

indicated in item 3.1(b) of this plan.

1902(e)(7) (vii) Inpatient services that are being of the Act furnished to infants and children described in

section 1902(1)(1)(B) -through (D), or section 1905(n)(2) of the Act on the date the infant or child attains the maximum age for coverage under the approved State plan will continue until the end of the stay for which the inpatient services are furnished.

1902(e)(9) (viii) Respiratory care services are provided to of the Act ventilator dependent individuals as indicated in

item 3.1(h) of this plan.

1902(a)(52) (ix) Services are provided to families eligible and 1925 under section 1925 of the Act as indicated in item of the Act 3.5 of this plan.

1905(a)(23) (x) Home and Community Care for Functionally and 1929 Disabled Elderly Individuals, as defined, described

and limited in Supplement 2 to Attachment 3.1-A and Appendices A-G to Supplement 2 to Attachment 3.1-A.

ATTACHMENT 3.1-A identifies the medical and remedial services provided to the categorically needy, specifies all limitations on the amount, duration and scope of those services, and lists the additional coverage (that is in excess of established service limits) for pregnancy-related services and services for conditions that may complicate the pregnancy.


TN No. MS-92-1

19c State/Territory: Nebraska Citation 3.1(a)(1) Amount, Duration, and Scope of Services: Categorically Needy (Continued) 1905(a)(26) and 1934

__X__ Program of All-Inclusive Care for the Elderly (PACE) services, as described and limited in Supplement 4 to Attachment 3.1-A.

ATTACHMENT 3.1-A identifies the medical and remedial services provided to the categorically needy. (Note: Other programs to be offered to Categorically Needy beneficiaries would specify all limitations on the amount, duration and scope of those services. As PACE provides services to the frail elderly population without such limitation, this is not applicable for this program. In addition, other programs to be offered to Categorically Needy beneficiaries would also list the additional coverage -that is in excess of established service limits- for pregnancy-related services for conditions that may complicate the pregnancy. As PACE is for the frail elderly population, this also is not applicable for this program.)

TN No. NE 12-04 Supersedes Approval Date OCT 24 2012 Effective Date FEB 01 2013 TN No. New page

20 Revision: HCFA-PM-91- (BPD) OMB No. 0938- 1991 State/Territory: Nebraska Citation

3.1 Amount. Duration. and Scope of Services (continued)

42 CFR Part 440, (a) (2) Medically needy. Subpart B

This State plan covers the medically needy. The services described below and in ATTACHMENT 3.1-B are provided.

Services for the medically needy include:

1902(a)(10)(C)(iv) (i) If services in an institution for mental of the Act diseases (42 CFR 440.140 and 440.160) or an 42 CFR 440.220 intermediate care facility for the mentally

retarded (or both) are provided to any medically needy group, then each medically needy group is provided either the services listed in section 1905(a)(1) through (5) and (17) of the Act, or seven of the services listed in section 1905(a)(1)through (20). The services are provided as defined in 42 CFR Part 440, Subpart A and in sections 1902, 1905, and 1915 of the Act.

Not applicable with respect to nurse-midwife services under section 1902(a)(17). Nurse-

midwives are not authorized to practice in this State.

1902(e)(5) of (ii) Prenatal care and delivery services for the Act pregnant women.

TN No. MS-92-1 Supersedes Approval Date Apr 10 1992 Effective Date Nov 1 1991


20a Revision: HCFA-PM-91 (BPD) OMB No. 0938- 1991 State/Territory: Nebraska Citation

3.1(a)(2) Amount, Duration, and Scope of Services: Medically Needy

(Continued)

(iii) Pregnancy-related, including family planning services, and postpartum services for a 60-day period (beginning on the day the pregnancy ends) and any remaining days in the month in which the 60th day falls are provided to women who, while pregnant, were eligible for, applied for, and received medical assistance on the day the pregnancy ends.

(iv) Services for any other medical condition that may

complicate the pregnancy (other than pregnancy related and postpartum services) are provided to pregnant women.

(v) Ambulatory services, as defined in ATTACHMENT 3.1-B,

for recipients under age 18 and recipients entitled to institutional services.

Not applicable with respect to recipients entitled

to institutional services; the plan does not cover those services for the medically needy.

1902(a)(10)(c) (vi) Home health services to recipients entitled to nursing facility

services as indicated in item 3.1(b) of this plan.

(vii) Services in an institution for mental diseases for individuals over age 65.

42 CFR 440.140, (viii) Services in an intermediate care facility for the 440.150, 440.160, mentally retarded. Subpart B 442.441, Subpart C (ix) Inpatient psychiatric services for individuals under 1902(a)(20) age 21. and (21) of the Act

TN No. MS-92-1 Supersedes Approval Date Apr 10 1992 Effective Date Nov 1 1991


20b Revision: HCFA-PM-93-5 (MB) May 1993 State/Territory: Nebraska Citation

3.1(a)(2) Amount, Duration, and Scope of Services: Medically Needy (Continued)

1902(e)(9) of Act (x) Respiratory care services are provided to ventilator dependent individuals as indicated in item 3.1(h) of this plan.

1905(a)(23) (xi) Home and Community Care for Functionally and 1929 of the Act Disabled Elderly Individuals, as defined, described

and limited in Supplement 2 to Attachment 3.1-A and Appendices A-G to Supplement 2 to Attachment 3.1-A.

ATTACHMENT 3.1-B identifies the services provided to each covered group of the medically needy; specifies all limitations on the amount, duration, and scope of those items; and specifies the ambulatory services provided under this plan and any limitations on them. It also lists the additional coverage (that is in excess of established service limits) for pregnancy-related services and services for conditions that may complicate the pregnancy.

TN No. MS-93-11 Supersedes Approval Date Jul 12 1993 Effective Date Apr 1 1993

TN No. MS-92-22

20c State/Territory: Nebraska Citation 3.1(a)(2) Amount, Duration, and Scope of Services: Medically Needy (Continued) 1905(a)(26) and 1934

_X__ Program of All-Inclusive Care for the Elderly (PACE) services, as described and limited in Supplement 4 to Attachment 3.1-A.

ATTACHMENT 3.1-B identifies services provided to each covered group of the medically needy. (Note: Other programs to be offered to Medically Needy beneficiaries would specify all limitations on the amount, duration and scope of those services. As PACE provides services to the frail elderly population without such limitation, this is not applicable for this program. In addition, other programs to be offered to Medically Needy beneficiaries would also list the additional coverage -that is in excess of established service limits- for pregnancy-related services for conditions that may complicate the pregnancy. As PACE is for the frail elderly population, this also is not applicable for this program.)

TN No. NE 12-04 Supersedes Approval Date OCT 24 2012 Effective Date FEB 01 2013 TN No. New page

21 Revision: HCFA-AT-9801 (CMSO) April 1998 State/Territory: Nebraska Citation

3.1 Amount, Duration, and Scope of Services (continued) (a)(3) Other Required Special Groups: Qualified Medicare Beneficiaries

1902(a)(10)(E)(i) and Medicare cost sharing for qualified Medicare clause (VIII) of the matter beneficiaries described in section1905(p) following (F), of the Act is provided only as indicated in item and 1905(p)(3) 3.2 of this plan. of the Act

1902(a)(10)(E)(ii) and (a)(4)(i) Other Required Special Groups: Qualified 1905(s) of the Act Disabled and Working Individuals

Medicare Part A premiums for qualified disabled and working individuals described in section 1902(a)(10)(E) (ii) of the Act are provided as indicated in item 3.2 of this plan.

1902(a)(10)(E)(iii) and (ii) Other Required Special Groups: Specified 1905(p)(3)(A)(ii) Low-Income Medicare Beneficiaries of the Act

Medicare Part B premiums for specified low- income Medicare beneficiaries described in section 1902(a)(10)(E)(iii) of the Act are provided as indicated in item 3.2 of this plan.

1902(a)(10)(E)(iv)( I), (iii) Other Required Special Groups: Qualifying 1905(p)(3)(A)(ii), and Individuals -1 1933 of the Act

Medicare Part B premiums for qualifying individuals described in 1902(a)(10)(E)(iv)(I) and subject to 1933 of the Act are provided as indicated in item 3.2 of this plan.

TN No. MS-98-1 Supersedes Approval Date May 8 1998 Effective Date Jan 1 1998

TN No. MS-93-4

21 (continued) Revision: HCFA-PM-98-1 (CMSO) April 1998 State/Territory: Nebraska Citation 1902(a)(10)(E)(iv)(II), (iv) Other Required Special Groups: Qualifying 1905(p)(3)(A)(iv)(II), Individuals -2 1905(p)(3) of the Act

The portion of the amount of increase to the Medicare Part B premium attributable to the Home Health provisions for quali fying individuals described in 1902(A)(10)(E)(iv)(II) and subject to 1933 of the Act are provided as indicated in item 3.2 of this plan.

1925 of the Act (a)(5) Other Required Special Groups: Families

Receiving Extended Medicaid Benefits

Extended Medicaid benefits for families described in section 1925 of the Act are provided as indicated in item 3.5 of this plan.


TN No. MS-93-4

21(a) Revision: HCFA-PM-98-1 (CMSO) April 1998 State/Territory: Nebraska Citation

Sec. 245A(h) of the (a)(6) Limited Coverage for Certain Aliens Immigration and Nationality Act (i) Aliens granted lawful temporary resident

status under section 245A of the Immigration and Nationality Act who meet the financial and categorical eligibility requirements under the approved State Medicaid plan are provided the services covered under the plan if they –

(A) Are aged, blind or disabled

individuals as defined in section 1614(a)(1) of the Act;

(B) Are children under 18 years of

age; or

(C) Are Cuban or Haitian entrants as defined in section 501(e)(1) and (2)(A) of P.L. 96422 in effect on April 1, 1983.

(ii) Except for emergency services and

pregnancy- related services, as defined in 42 CFR 447.53(b) aliens granted lawful temporary resident status under section 245A of the Immigration and Nationality Act who are not identified in items 3.1(a)(6)(i)(A) through (C) above, and who meet the financial and categorical eligibility requirements under the approved State plan are provided services under the plan no earlier than five years from the date the alien is granted lawful temporary resident status.


TN No. MS-93-4

21b State/Territory: Nebraska Citation 1905(a)(9) of (a)(7) Homeless Individuals the Act

Clinic services furnished to eligible individuals who do reside in a permanent dwelling or do not have a fixed home or mailing address are provided without restrictions regarding the site at which the services are furnished.

1902(a)(47) of (a)(8) Presumptively Eligible Pregnant Women the Act

Ambulatory prenatal care for pregnant women is provided during a presumptive eligibility period if the care is furnished by a provider that is eligible for payment under the State plan.

42 CFR 441.55 (a)(9) EPSDT Services 50 FR 43654 1902(a)(43), The Medicaid agency meets the requirements of 1905(a)(4)(B), sections 1902(a)(43), 1905(a)(4)(B), and 1905(r) and 1905(r) of or the Act with respect to early and periodic the Act screening, diagnostic, and treatment (EPSDT) services. TN No. MS-97-11 Supersedes Approval Date Feb 9 1998 Effective Date

TN No. MS-92-1

22 Revision: HCFA-AT-91- (BPD) OMB No. 0938- 1991 State/Territory: Nebraska Citation

3.1 (a)(9) Amount, Duration, and Scope of Services:

EPSDT Services (continued)

42 CFR 441.60 The Medicaid agency has in effect agreements with continuing care providers. Described below are the methods employed to assure the providers' compliance with their agreements.

(a)(10) Comparability of Services

42 CFR 440.240 Except for those items or services for which and 440.250 sections 1902(a), 1902(a)(10), 1903(v), 1915, 1925,

and 1932 of the Act, 42 CFR 440.250 and section245A of the Immigration and Nationality Act,

1902(a) and 1902 permit exceptions: (a)(10), 1902(a)(52), 1903(v), 1915(g), (i) Services made available to the categorically 1925(b)(4) and 1932, needy are equal in amount, duration, and of the Act. scope for each categorically needy person.

(ii) The amount, duration, and scope of services

made available to the categorically needy are equal to or greater than those made available to the medically needy.

(iii) Services made available to the medically needy

are equal in amount, duration, and scope for each person in a medically needy coverage group.

(iv) Additional coverage for pregnancy-related

services and services for conditions that may complicate the pregnancy are equal for categorically and medically needy.

**Describe here. The MCO submits monthly encounter data.


TN No. MS-92-1

23

Revision: HCFA-AT-80-38 (BPP) May 22, 1980 State/Territory: Nebraska Citation 3.1(b) Home health services are provided in 42 CFR Part accordance with the requirements of 42 CFR 440, Subpart B 441.15. 42 CPR 441.15 AT -78-90 (1) Home health services are provided to AT-80-34 all categorically needy individuals 21 years of age or over. (2) Home health services are provided to all

categorically needy individuals under 21 years of age.

Yes Not applicable. The State plan does not

provide for skilled nursing facility services for such individuals.

(3) Home health services are provided to the

medically needy: Yes, to all Yes, to individuals age 21 or over; SNF

services are provided Yes, to individuals under age 21; SNF

services are provided No; SNF services are not provided Not applicable; the medically needy are

not included under this plan TN No. MS-80-1 Supersedes Approval Date Apr 17 1980 Effective Date Jan 1 1980

TN No.

24 Revision: HCFA-PM-93-8 (BPD) December 1993 State/Territory: Nebraska Citation 3.1 Amount, Duration, and Scope of Services (continued) 42 CFR 431.53 (c)(1) Assurance of Transportation

Provision is made for assuring necessary transportation of recipients to and from providers. Methods used to assure such transportation are described in ATTACHMENT 3.1-D.

42 CFR 483.10 (c)(2) Payment for Nursing Facility Services

The State includes in nursing facility services at least the items and services specified in 42 CFR 483.10 (c) (8) (i).


TN No. MS-91-24


3.1(d) Methods and Standards to Assure Quality of Services

42 CFR 440.260 The standards established and the methods used to AT-78-90 assure high quality care are described in

ATTACHMENTS 3.1-C. TN No. MS-76-14 Supersedes Approval Date Dec 3 1976 Effective Date Dec 1 1976

TN No. MS-74-10


3.1(e) Family Planning Services

42 CFR 441.20 The requirements of 42 CFR 441.20 are met regarding freedom AT-78-90 from coercion or pressure of mind and conscience, and freedom of

choice of method to be used for family planning.


TN No. MS-74-10

27 Revision: HCFA-PM-87-5 (BERC) OMB No.: 0938-0193 April 1987 State/Territory: Nebraska Citation

3.1(f)(1) Optometric Services 42 CFR 441.30 Optometric services (other than those provided AT-78-90 under §435.531 and 436.531) are not now but were previously provided under the plan. Services of the type

an optometrist is legally authorized to perform are specifically included in the term "physicians' services" under this plan and are reimbursed whether furnished by a physician or an optometrist.

Yes.

No. The conditions described in the first

sentence apply but the term "physicians' services" does not specifically include services of the type an optometrist is legally authorized to perform.

Not applicable. The conditions in the first

sentence do not apply.

(2) Organ Transplant Procedures 1903(i)(1) Organ transplant procedures are provided. of the Act, P.L. 99-272 No (Section 9507)

Yes. Similarly situated individuals are treated alike and any restriction on the facilities that may, or practitioners who may, provide those procedures is consistent with the accessibility of high quality care to individuals eligible for the procedures under this plan. Standards for the coverage of organ transplant procedures are described at ATTACHMENT 3.1-E.

TN No. MS-87-12 Supersedes Approval Date Jul 24 1987 Effective Date Jul 1 1987


28 Revision: HCFA-PM-87-4 (BERC) OMB No. 0938-0193 March 1987 State/Territory: Nebraska Citation

3.1 (g) Participation by Indian Health Service Facilities

42 CFR Indian Health Service facilities are accepted as 431.110(b) providers, in accordance with 42 CFR 431.110(b), on the AT-78-90 same basis as other qualified providers.

(h) Respiratory Care Services for Ventilator-Dependent Individuals

1902(e)(9) of the Act, Respiratory care services, as defined in section 1902(e)(9)(C) P.L. 99-509 of the Act, are provided under the plan to individuals who-- (Section 9408)

(1) Are medically dependent on a ventilator for life support at least six hours per day;

(2) Have been so dependent as inpatients during a single stay

or a continuous stay in one or more hospitals, SNFs or ICFs for the lesser of--

30 consecutive days;

___ days (the maximum number of inpatient

days allowed under the State plan);

(3) Except for home respiratory care, would require respiratory care on an inpatient basis in a hospital, SNF, or ICF for which Medicaid payments would be made;

(4) Have adequate social support services to be cared for at

home; and (5) Wish to be cared for at home.

Yes. The requirements of section 1902(e)(9) of the Act are met. Not applicable. These services are not included in the plan.



29 Revision: HCFA-PM-93-5 (MB) May 1993 State/Territory: Nebraska Citation

3.2 Coordination of Medicaid with Medicare and Other Insurance (a) Premiums (1) Medicare Part A and Part B 1902(a)(10)(E)(i) (i) Qualified Medicare Beneficiary and 1905(p)(1) (QMB) of the Act

The Medicaid agency pays Medicare Part A premiums (if applicable) and Part B premiums for individuals in the QMB group defined in Item A.25 of ATTACHMENT 2.2-A, through the group premium payment arrangement, unless the agency has a Buy-in agreement for such payment, as indicated below.

Buy-In agreement for:

Part A Part B

The Medicaid agency pays

premiums, for which the beneficiary would be liable, for enrollment in an HMO participating in Medicare.

TN No. MS-93-11 Supersedes Approval Date Jul 12 1993 Effective Date Apr 1 1993

TN No. MS-93-4

29a Revision: HCFA-PM-93-2 (MB) March 1993 State/Territory: Nebraska Citation

(ii) Qualified Disabled and Working Individual (QDWI) 1902(a)(10)(E)(ii) and The Medicaid agency pays Medicare 1905(s) of the Act Part A premiums under a group premium

payment arrangement, subject to any contribution required as described in ATTACHMENT 4.18-E, for individuals in the QDWI group defined in item A.26 of ATTACHMENT 2.2-A of this plan.

1902(a)(10)(E)(iii) and (iii) Specified Low-Income Medicare 1905(p)(3)(A)(iii) Beneficiary (SLMB) of the Act

The Medicaid agency pays Medicare Part B premiums under the State buy-in process for individuals in the SLMB group defined in item A.27 of ATTACHMENT 2.2-A of this plan.

1902(a)(10)(E)(iv)(I), (iv) Qualifying Individual - 1 (OI-1) 1905(p)(3)(A)(ii), and 1933 of the Act The Medicaid agency pays Medicare Part

B premiums under the State buy-in process for individuals described in 1902(a)(10)(E)(iv)(l) and subject to 1933 of the Act.

1902(a)(10)(E)(iv)(II), (iv) Qualifying Individual - 2 (OI-2) 1905(p)(3)(A)(ii), and 1933 of the Act The Medicaid agency pays the portion of the amount of increase to the Medicare

Part B premium attributable to the Home Health Provision to the individuals described in 1902(a)(10)(E)(iv)(II) and subject to 1933 of the Act.


TN No. MS-93-4

29b Revision: HCFA-PM-93-2 (MB) March 1993 State/Territory: Nebraska Citation (iv) Other Medicaid Recipients 1843(b) and 1905(a) The Medicaid agency pays Medicare of the Act and 42 CFR 431.625 Part B premiums to make Medicare Part B coverage available to the following individuals:

All individuals who are: a) receiving

benefits under titles I, IV-A, X, XIV, or XVI (AABD or SSI); b) receiving State supplements under title XVI; or c) within a group listed at 42 CFR 431.625(d)(2).

Individuals receiving title II or Railroad Retirement benefits.

Medically needy individuals (FFP is not available for this group).

(2) Other Health Insurance 1902(a)(30) and The Medicaid agency pays insurance 1905(a) of the Act premiums for medical or any other type of remedial care to maintain a third party resource for Medicaid covered services provided to eligible individuals (except individuals 65 years of age or older and disabled individuals, entitled to Medicare Part A but not enrolled in Medicare Part B). TN No. MS-98-1 Supersedes Approval Date May 8 1998 Effective Date Jan 1 1998

TN No. MS-93-4

29c Revision: HCFA-PM-93-2 (MB) March 1993 State/Territory: Nebraska Citation (b) Deductibles/Coinsurance (1) Medicare Part A and B 1902(a)(30), 1902(n), Supplement 1 to ATTACHMENT 4.19-B describes the methods 1905(a),and 1916 and standards for establishing payment rates for services covered of the Act under Medicare, and/or the methodology for payment of Medicare

deductible and coinsurance amounts, to the extent available for each of the following groups. (i) Qualified Medicare Beneficiaries (QMBS)

Sections 1902 The Medicaid agency pays Medicare Part A and Part B (a)(10)(E)(i) and deductible and coinsurance amounts for QMBs (subject 1905(p)(3) of the Act to any nominal Medicaid copayment) for all services

available under Medicare. (ii) Other Medicaid Recipients

1902(a)(10), 1902(a)(30), The Medicaid agency pays for Medicaid services also and 1905(a) of the Act covered under Medicare and furnished to recipients

entitled to Medicare(subject to any nominal Medicaid copayment). For services furnished to individuals who

are described in section 3.2(a)(1)(iv),payment is made as follows:

42 CFR 431.625 For the entire range of services available under

Medicare Part B Only for the amount, duration, and scope of services otherwise available under this plan.

1902(a)(10), 1902(a)(30), (iii) Dual Eligible--QMB plus 1905(a), and 1905(p) of the Act The Medicaid agency pays Medicare Part A and Part B

deductible and coinsurance amounts for all services available under Medicare and pays for all Medicaid

services furnished to individuals eligible both as QMBs and categorically or medically needy (subject to any nominal Medicaid copayment).

TN No. MS-93-4 Supersedes Approval Date Jun 19 1998 Effective Date Jan 1 1993 TN No. MS-92-1

29d

Revision: HCFA-PM-91-8 (MB) OMB No. : October 1991 State/Territory: Nebraska Citation

(c) Premiums, Deductibles, Coinsurance and Other Cost Sharing Obligations 1906 of the Act The Medicaid agency pays all premiums,

deductibles, coinsurance and other cost sharing obligations for items and services covered under the State plan (subject to any nominal Medicaid copayment) for eligible individuals in employer-based cost-effective group health plans. When coverage for eligible family members is not possible unless ineligible family members enroll, the Medicaid agency pays premiums for enrollment of other family members when cost-effective. In addition, the eligible individual is entitled to services covered by the State plan which are not included in the group health plan. Guidelines for determining cost effectiveness are described in section 4.22(h).

1902(a)(10)(F) (d) The Medicaid agency pays premiums for individuals of the Act described in item19 of Attachment 2.2-A. TN No. MS-91-29 Supersedes Approval Date Jan 15 1992 Effective Date Oct 1 1991

TN No. New Page HCFA ID: 7983E


3.3 Medicaid for Individuals Age 65 or Over in Institutions for Mental Diseases

42 CFR 441.101, Medicaid is provided for individuals 65 years of age or older who 42 CFR 431.620(c) are patients in institutions for mental diseases. and (d) AT-79-29 Yes. The requirements of 42 CFR Part 441, Subpart C,

and 42 CFR 431.620(c) and (d) are met. Not applicable. Medicaid is not provided to aged

individuals in such institutions under this plan.


TN No. MS-74-9

31 Revision: HCFA-AT-80-38 (BPP) May 22, 1980 State/Territory: Nebraska Citation 3.4 Special Requirements Applicable to Sterilization Procedures 42 CFR 441.252 All requirements of 42 CFR Part 441, Subpart F are met. AT"78-99

TN No. MS-79-1 Supersedes Approval Date Apr 3 1979 Effective Date Feb 2 1979

TN No. MS-76-14

31a Revision: HCFA-PM-91-4 (BPD) OMB No. 0938- August 1991 State/Territory: Nebraska Citation 3.5 Families Receiving Extended Medicaid Benefits 1902(a)(52) and (a) Services provided to families during the first 1925 of the Act 6-month period of extended Medicaid benefits under Section 1925 of the Act are equal in amount, duration, and scope to services provided to categorically needy AFDC recipients as described in ATTACHMENT 3.1-A (or may be greater if provided through a caretaker relative employer's health insurance plan). (b) Services provided to families during the second 6-month period of extended Medicaid benefits under section 1925 of the Act are - Equal in amount, duration,and scope to

services provided to categorically needy AFDC recipients as described in ATTACHMENT 3.1-A (or may be greater if provided through a caretaker relative employer's health insurance plan).

Equal in amount, duration, and scope to services

provided to categorically needy AFDC recipients, (or may be greater if provided through a caretaker relative employer's health insurance plan) minus any one or more of the following acute services:

Nursing facility services (other than services

in an institution for mental diseases) for individuals 21 years of age or older.

Medical or remedial care provided

by licensed practitioners. Home health services. TN No. MS-91-24 Supersedes Approval Date Jan 20 1992 Effective Date Nov 1 1991


31b Revision: HCFA-PM-91-4 (BPD) OMB No. 0938- August 1991 State/Territory: Nebraska Citation 3.5 Families Receiving Extended Medicaid Benefits (Continued) Private duty nursing services. Physical therapy and related services Other diagnostic, screening, preventive, and rehabilitation services. Inpatient hospital services and nursing facility services for individuals 65 years of age or over in an institution for mental diseases. Intermediate care facility services for the mentally retarded. Inpatient psychiatric services for individuals under age 21. Hospice services. Respiratory care services.

Any other medical care and any other type of remedial care recognized under State law and specified by the Secretary.



31c Revision: HCFA-PM-91-4 (BPD) OMB No. 0938- August 1991 State/Territory: Nebraska Citation 3.5 Families Receiving Extended Medicaid Benefits (Continued) (c) The agency pays the family's premiums, enrollment fees, deductibles, coinsurance, and similar costs for health plans offered by the

caretaker's employer as payments for medical assistance—

1st 6 months 2nd 6 months

The agency requires caretakers to enroll in employers' health plans as a condition of eligibility.

1st 6 mos. 2nd 6 mos.

(d) (1) The Medicaid agency provides assistance to families during the second 6-month period of extended Medicaid benefits through the following alternative methods:

Enrollment in the family option of an employer's health plan. Enrollment in the family option of a State employee health plan. Enrollment in the State health plan for the uninsured. Enrollment in an eligible health maintenance organization (HMO) with a prepaid enrollment of less than 50 percent Medicaid recipients (except recipients of extended Medicaid). TN No. MS-91-24 Supersedes Approval Date Jan 20 1992 Effective Date Nov 1 1991


31d Revision: HCFA-PM-91-4 (BPD) OMB No. 0938- August 1991 State/Territory: Nebraska Citation 3.5 Families Receiving Extended Medicaid Benefits (Continued)

Supplement 2 to ATTACHMENT 3.1-A specifies and describes the alternative health care plan(s) offered, including requirements for assuring that recipients have access to services of adequate quality. (2) The agency—

(i) Pays all premiums and enrollment fees imposed on the family for such plan(s). (ii) Pays all deductibles and coinsurance imposed on the family for such plan(s). TN No. MS-91-24 Supersedes Approval Date Jan 20 1992 Effective Date Nov 1 1991


32 Revision: HCFA-PM-87-4 (BERC) OMB No. 0938-0193 March 1987 State/Territory: Nebraska

SECTION 4 – GENERAL PROGRAM ADMINISTRATION Citation 4.1 Methods of Administration 42 CFR 431.15 The Medicaid agency employs methods of administration AT-79-29 found by the Secretary of Health and Human Services to be necessary for the proper and efficient operation of the plan. TN No. MS-87-11 Supersedes Approval Date Aug 6 1987 Effective Date Apr 1 1987


33 Revision: HCFA RO VII November 1990 State/Territory: Nebraska Citation 4.2 Hearings for Applicants and Recipients 42 CFR 431.202 The Medicaid agency has a system of hearings that meets AT-79-29 all the requirements of 42 CFR Part 431, Subpart E. AT-80-34 With respect to transfers and discharges from nursing 1919(e)(3) facilities, the requirements of 1919(e)(3) are met. TN No. MS-91-1 Supersedes Approval Date Jan 18 1991 Effective Date Oct 1 1990

TN No. MS-74-7

34 Revision: HCFA-AT-87-9 (BERC) OMB No. 0938-0193 August 1987 State/Territory: Nebraska Citation 4.3 Safeguarding Information on Applicants and Recipients 42 CFR 431.301 Under State statute which imposes legal sanctions, AT-79-29 safeguards are provided that restrict the use or disclosure of information concerning applicants and recipients to purposes directly connected with the administration of the plan. 52 FR 5967 All other requirements of 42 CFR Part 431, Subpart F are met. TN No. MS-87-17 Supersedes Approval Date Oct 4 1988 Effective Date Oct 1 1987


35 Revision: HCFA-PM-87-4 (BERC) OMB No. 0938-0193 March 1987 State/Territory: Nebraska Citation 4.4 Medicaid Quality Control 42 CFR (a) A system of quality control is implemented in 431.800(c) accordance with 42 CFR Part 431, Subpart P. 50 FR 21839 1903(u)(1)(D) (b) The State operates a claims processing assessment of the Act, system that meets the requirements of 431.800(e), P.L. 99-509 (g), (h), (j) and (k). (Section 9407) Yes. Not applicable. The State has an approved Medicaid Management Information System (MMIS). TN No. MS-87-11 Supersedes Approval Date Aug 6 1987 Effective Date Apr 1 1987

TN No. MS-85-12 HCFA ID: 1010P/0012P

36 Revision: HCFA-PM-88-10 (BERC) OMB No. 0938-0193 September 1988 State/Territory: Nebraska Citation 4.5 Medicaid Agency Fraud Detection and Investigation Program 42 CFR 455.12 The Medicaid agency has established and will maintain AT-78-90 methods, criteria and procedures that meet all requirements 48 FR 3742 of 42 CFR 455.13 through 455.21 and 455.23 for prevention 52 FR 48817 and control of program fraud and abuse. TN No. MS-88-14 Supersedes Approval Date Jan 23 1989 Effective Date Oct 1 1988


36a HCFA-PM-99-3 (CMSO) June 1999 State/Territory: Nebraska

Citation 4.5a Medicaid Agency Fraud Detection and Investigation Section 1902 The Medicaid agency has established a mechanism to (a)(64) of the receive reports from beneficiaries and others and Social Security Act compile data concerning alleged instances of waste, fraud, P.L. 105-33 and abuse relating to the operation of this title. TN No. MS-01-07 Supersedes Approval Date Jul 5 2001 Effective Date Jun 1 1999

TN No. NA

36b Revision: (Draft) State/Territory: Nebraska 4.5b Medicaid Recovery Audit Contractor Program

Citation Section 1902(a)(42)(B)(i) of the Social Security Act Section 1902(a)(42)(B)(ii)(I) of the Act Section 1902 (a)(42)(B)(ii)(II)(aa) of the Act

_____ The State has established a program under which it will contract with one or more recovery audit contractors (RACs) for the purpose of identifying underpayments and overpayments of Medicaid claims under the State plan and under any waiver of the State plan. __X__ The State is seeking an exception to establishing such program for the following reasons: Nebraska implemented Heritage Health effective January 1, 2017. Heritage Health combines physical health, behavioral health and pharmacy programs into a single managed care system. More than 99% of Nebraska Medicaid clients are enrolled in Managed Care. A dental benefits manager for dental services was effective October 1, 2017. Neb Rev Stat 68-974(3)(a) excludes Managed Care claims from the scope of the Recovery Audit Contractor. This leaves very few claims for review or recovery from the fee for service program. _____ The State/Medicaid agency has contracts of the type(s) listed in section 1902(a)(42)(B)(ii)(I) of the Act. All contracts meet the requirements of the statute. RACs are consistent with the statute. Place a check mark to provide assurance of the following: ______ The State will make payments to the RAC(s) only from amounts recovered. ______ The State will make payments to the RAC(s) on a contingent basis for collecting overpayments. The following payment methodology shall be used to determine State payments to Medicaid RACs for identification and recovery of overpayments (e.g., the percentage of the contingency fee): ______ The State attests that the contingency fee rate paid to the Medicaid RAC will not exceed the highest rate paid to Medicare RACs, as published in the Federal Register.

TN No. NE 19-0013 Supersedes Approval Date 12/23/2019 Effective Date 12/01/2019 TN No. NE 17-0019

TN No. NE 19-0013 Supersedes Approval Date 12/23/2019 Effective Date 12/01/2019 TN No. NE 17-0019

Revisions: (Draft) State/Territory: Nebraska Section 1902 (a)(42)(B)(ii)(II)(bb) of the Act Section 1902 (a)(42)(B)(ii)(III) of the Act Section 1902 (a)(42)(B)(ii)(IV)(aa) of the Act Section 1902(a)(42)(B)(ii)(IV)(bb) of the Act Section 1902 (a)(42)(B)(ii)(IV)(cc) Of the Act

36c (4.5b Continued) ______ The State attests that the contingency fee rate paid to the

Medicaid RAC will exceed the highest rate paid to Medicare RACs, as published in the Federal Register. The State will only submit for FFP up to the amount equivalent to that published rate.

______ The contingency fee rate paid to the Medicaid RAC that

will exceed the highest rate paid to Medicare RACs, as published in the Federal Register. The State will submit a justification for that rate and will submit for FFP for the full amount of the contingency fee.

______ The following payment methodology shall be used to

determine State payments to Medicaid RACs for the identification of underpayments (e.g., amount of flat fee, the percentage of the contingency fee):

Flat fee to be negotiated ______ The State has an adequate appeal process in place for

entities to appeal any adverse determination made by the Medicaid RAC(s).

______ The State assures that the amounts expended by the

State to carry out the program will be amounts expended as necessary for the proper and efficient administration of the State plan or a waiver of the plan.

______ The State assures that the recovered amounts will be

subject to a State’s quarterly expenditure estimates and funding of the State’s share.

______ Efforts of the Medicaid RAC(s) will be coordinated with

other contractors or entities performing audits of entities receiving payments under the State plan or waiver in the State, and/or State and Federal law enforcement entities and the CMS Medicaid Integrity Program.

37 Revision: HCFA-AT-80-38 (BPP) May 22, 1980 State/Territory: Nebraska Citation 4.6 Reports 42 CFR 431.16 The Medicaid agency will submit all reports in the form AT-79-29 and with the content required by the Secretary, and will comply with any provisions that the Secretary finds necessary to verify and assure the correctness of the reports. All requirements of 42 CFR 431.16 are met. TN No. MS-77-6 Supersedes Approval Date Jan 5 1978 Effective Date Dec 31 1977

TN No. MS-75-10

38 Revision: HCFA-AT-80-38 (BPP) May 22, 1980 State/Territory: Nebraska Citation 4.7 Maintenance of Records 42 CFR 431.17 The Medicaid agency maintains or supervises AT-79-29 the maintenance of records necessary for the proper and

efficient operation of the plan, including records regarding applications, determination of eligibility, the provision of medical assistance, and administrative costs, and statistical, fiscal and other records necessary for reporting and accountability, and retains these records in accordance with Federal requirements. All requirements of 42 CFR 431.17 are met.

TN No. MS-77-6 Supersedes Approval Date Jan 5 1978 Effective Date Dec 31 1977

TN No. MS-75-10

39 Revision: HCFA-AT-80-38 (BPP) May 22, 1980 State/Territory: Nebraska Citation 4.8 Availability of Agency Program Manuals 42 CFR 431.18(b) Program manuals and other policy issuances that AT-79-29 affect the public, including the Medicaid agency's rules and

regulations governing eligibility, need and amount of assistance, recipient rights and responsibilities, and services offered by the agency are maintained in the State office and in each local and district office for examination, upon request, by individuals for review, study, or reproduction. All requirements of 42 CFR 431.18 are met.

TN No. MS-74-5 Supersedes Approval Date Aug 16 1974 Effective Date Jun 1 1974

TN No. MS-74-1

40 Revision: HCFA-AT-80-38 (BPP) May 22, 1980 State/Territory: Nebraska Citation 4.9 Reporting Provider Payments to Internal Revenue Service 42 CFR 433.37 There are procedures implemented in accordance with 42 AT-78-90 CFR 433.37 for identification of providers of services by social security number or by employer identification number and for reporting the information required by the Internal Revenue Code (26 U.S.C.6041) with respect to payment for services under the plan. TN No. MS-74-5 Supersedes Approval Date Aug 16 1974 Effective Date Jun 1 1974

TN No. MS-74-1

41 Revision: HCFA-AT-99-3 (CMSO) June 1999 State/Territory: Nebraska Citation 4.10 Free Choice of Providers 42 CFR 431.51 (a) Except as provided in paragraph (b), the Medicaid agency AT-78-90 assures that an individual eligible under the plan may 46 FR 48524 obtain Medicaid services from any institution, agency, 48 FR 23212 pharmacy, person, or organization that is qualified to 1902(a)(23) perform the services, including of the Act an organization P.L. 100-93 that provides these services or arranges for their (section 8(f) availability on a prepayment basis. P.L. 100-203 (Section 4113) (b) Paragraph (a) does not apply to services furnished to an individual — (1) Under an exception allowed under 42 CFR 431.54, subject to the limitations in paragraph(c), or

(2) Under a waiver approved under 42 CFR 431.55, subject to the limitations in paragraph (c), or

(3) By an individual or entity excluded from participation in

accordance with section 1902(p) of the Act,

Section 1902(a)(23) (4) By individuals or entities who have been Of the Social convicted of a felony under Federal or State law Security Act and for which the State determines that the P.L. 105-33 offense is inconsistent with the best interests of the individual eligible to obtain Medicaid Services, or Section 1932(a)(1) (5) Under an exception allowed under 42 CFR Section 1905(t) 438.50 or 42 CFR 440.168, subject to the limitations in paragraph (c)

(c) Enrollment of an individual eligible for medical assistance in a primary care case management system described in section 1905(t), 1915(a), 1915(b)(1), or 1932(a); or managed care organization, prepaid inpatient health plan, a prepaid ambulatory health plan, or a similar entity shall not restrict the choice of the qualified person from whom the individual may receive emergency services or services under section 1905(a)(4)(c).


TN No. MS-01-07

Revision: HCFA-PM-80-38 (BPP) OMB No. 0938-0193 May 22, 1980 State/Territory: Nebraska Citation 4.11 Relations with Standard-Setting and Survey Agencies 42 CFR 431.610 (a) The State agency utilized by the Secretary to determine AT-78-90 qualifications of institutions and suppliers of services to AT-80-34 participate in Medicare is responsible for establishing

and maintaining health standards for private or public institutions (exclusive of Christian Science sanatoria) that provide services to Medicaid recipients. This agency is the Nebraska Department of Health and Human Services.

(b) The State authority(ies) responsible for establishing

and maintaining standards, other than those relating to health, for public or private institutions that provide services to Medicaid recipients is (are): Nebraska Health and Human Services System.

(c) ATTACHMENT 4.11-A describes the standards

specified in paragraphs (a) and (b) above, that are kept on file and made available to the Health Care Financing Administration on request.

TN No. MS-08-08 Supersedes Approval Date Dec 10 2008 Effective Date Sep 1 2008

TN No. MS-97-6

Revision: HCFA-PM-80-38 (BPP) OMB No. 0938-0193 May 22, 1980 State/Territory: Nebraska

Citation 4.11(d) The Nebraska Department of Health and Human Services, 42 CFR 431.610 which is the State agency responsible for licensing health AT-78-90 institutions, determines if institutions and agencies meet AT-89-34 the requirements for participation in the Medicaid program. The requirements in 42 CFR 431.610(e), (f) and (g) are met. TN No. MS-08-08 Supersedes Approval Date Dec 10 2008 Effective Date Sep 1 2008

TN No. MS-97-6

44 Revision: HCFA-AT-80-38 (BPP) May 22, 1980 State/Territory: Nebraska Citation 4.12 Consultation to Medical Facilities 42 CFR 431.105(b) (a) Consultative services are provided AT-78-90 by health and other appropriate State agencies to hospitals, nursing facilities, home health agencies, clinics and laboratories in accordance with 42 CFR 431.105(b). (b) Similar services are provided to other types of facilities providing medical care to individuals receiving services under the programs specified in 42 CFR 431.105(b). Yes, as listed below: Not applicable. Similar services are not provided to other types of medical facilities. TN No. MS-74-1 Supersedes Approval Date May 23 1974 Effective Date Jan 1 1974

TN No.

45 Revision: HCFA-PM-91-4 (BPD) OMB No. 0938- August 1991 State/Territory: Nebraska Citation 4.13 Required Provider Agreement With respect to agreements between the Medicaid agency and each provider furnishing services under the plan: 42 CFR 431.107 (a) For all providers, the requirements of 42 CFR 431.107 and 42 CFR Part 442, Subparts A and B (if applicable) are met. 42 CFR Part 483 (b) For providers of NF services, the requirements 1919 of the Act of 42 CFR Part 483, Subpart B, and section 1919 of the Act are also met. 42 CFR Part 483, (c) For providers of ICF/MR services, the requirements Subpart D of participation in 42 CFR Part 483, Subpart DI--are also met. 1920 of the Act (d) For each provider that is eligible under the plan to furnish ambulatory prenatal care to pregnant women during a presumptive eligibility period, all the requirements of section 1920(b)(2) and (c) are met. Not applicable. Ambulatory prenatal care is not provided to pregnant women during a presumptive eligibility period. TN No. MS-91-24 Supersedes Approval Date Jan 20 1992 Effective Date Nov 1 1991


45(a) Revision: HCFA-PM-91-9 (MB) OMB No.: October 1991 State/Territory: Nebraska Citation 4.13 (e) For each provider receiving funds under the plan, all 1902(a) (58) the requirements for advance directives of section 1902(w) 1902(w) are met: (1) Hospitals, nursing facilities, providers of home

health care or personal care services, hospice programs, managed care organizations, prepaid inpatient health plans, prepaid ambulatory health plans (unless the PAHP excludes providers in 42 CFR 489.102), and health insuring organizations are required to do the following:

(a) Maintain written policies and procedures with respect to all adult individuals receiving medical care by or through the provider or organization about their rights under State law to make decisions concerning medical care, including the right to accept or refuse medical or surgical treatment and the right to formulate advance directives.

(b) Provide written information to all adult individuals on their policies concerning implementation of such rights. (c) Document in the individual's medical

records whether or not the individual has executed an advance directive;

(d) Not condition the provision of care or

otherwise discriminate against an individual based on whether or not the individual has executed an advance directive;

(e) Ensure compliance with requirements of

State Law (whether TN No. MS-03-12 Supersedes Approval Date Nov 6 2003 Effective Date Aug 13 2003 TN No. MS-91-26

45(b) Revision: HCFA-PM-91-9 (MB) OMB No.: October 1991 State/Territory: Nebraska Citation statutory or recognized by the courts) concerning advance directives; and (f) Provide (individually or with others) for education for staff and the community on issues concerning advance directives. (2) Providers will furnish the written information described in paragraph (1)(a) to all adult individuals at the time specified below:

(a) Hospitals at the time an individual is admitted as an inpatient.

(b) Nursing facilities when the individual is

admitted as a resident. (c) Providers of home health care or

personal care services before the individual comes under the care of the provider;

(d) Hospice program at the time of initial

receipt of hospice care by the individual from the program; and

(e) Managed care organizations, health

insuring organizations, prepaid inpatient health plans, and prepaid ambulatory health plans (as applicable) at the time of enrollment of the individual with the organization.

(3) Attachment 4.34 A describes law of the State (whether statutory or as Recognized by the courts of the State) concerning advance directives. Not applicable. No State law or court decision exist regarding advance directives. TN No. MS-03-12 Supersedes Approval Date Nov 6 2003 Effective Date Aug 13 2003 TN No. MS-91-26

46 Revision: HCFA-PM-91-10 (MB) December 1991 State/Territory: Nebraska Citation 4.14 Utilization/Quality Control 42 CFR 431.60 (a) A Statewide program of surveillance and utilization control has 42 CFR 456.2 implemented that safeguards against unnecessary or inappropriate 50 FR 15312 use of Medicaid services available under this plan and against 1902(a)(30)(C) excess payments, and that assesses the quality of services. The and 1902(d) of requirements of 42 CFR Part 456 are met: the Act, P.L. 99-509 Directly (Section 9431)

By undertaking medical and utilization review requirements through a contract with a Utilization and Quality Control Peer Review Organization (PRO) designated under 42 CFR Part 462. The contract with the PRO —

(1) Meets the requirements of §434.6(a); (2) Includes a monitoring and evaluation plan to ensure

satisfactory performance; (3) Identifies the services and providers subject to PRO review; (4) Ensures that PRO review activities are not inconsistent with

the PRO review of Medicare services; and (5) Includes a description of the extent to which PRO

determinations are considered conclusive for payment purposes.

1902(a)(30)(c) By undertaking quality and utilization reviews through contracts and 1902(d) with utilization review organizations which do peer reviews of the Act, (PRO-like/non- PRO-like entities). One contract includes hospital P.L. 99-509 services (selected inpatient and selected out-patient services); (section 9431) the other contract includes mental health substance abuse

inpatient services A qualified External Quality Review Organization performs an

annual External Quality Review that meets the requirements of 42 CFR 438 Subpart E each managed care organization, prepaid inpatient health plan, and health insuring organizations under contract, except where exempted by the regulation.


TN No. MS-01-05

Substitute per letter dated 4/23/01 47 Revision: HCFA-PH-85-3 (BERC) May 1985 State/Territory: Nebraska

Citation The contracts with the entities —

(1) Meets the requirements of §434.6(a); (2) Includes a monitoring and evaluation plan

to ensure satisfactory performance; (3) Identifies the services and providers

subject to the entity's review-, (4) Includes a description of the extent to

which the entity's determinations are considered conclusive for payment purposes.

4.14 (b) The Medicaid agency meets the requirements of 42 CFR 42 CFR 456.2 Part 456, Subpart C, for control of the utilization of inpatient 50 FR 15312 hospital services.

Utilization and medical review are performed by a Utilization and Quality Control Peer Review Organization designated under 42 CFR Part 462 that has a contract with the agency to perform those reviews.

Utilization review is performed in accordance with 42

CFR Part 456, Subpart H, that specifies the conditions of a waiver of the requirements of Subpart C for.

AII hospitals (other than mental hospitals).

Those specified in the waiver.

No waivers have been granted. TN No. MS-01-05 Supersedes Approval Date May 10 2001 Effective Date Jan 1 2001

TN No. MS-91-21

Substitute per letter dated 4/23/01 48 Revision: HCFA-PH-85-3 (BERC) OMB No. 0938-0193 July 1985 State/Territory: Nebraska Citation 4.14(c) The Medicaid agency meets the requirements of 42 CFR 42 CFR 456.2 Part 456.Subpart D, for control 30 Fit 15312 of utilization of inpatient services in mental

hospitals. Utilization and medical review are performed by a Utilization and Quality Control Peer Review Organization designated under 42 CFR Part 462 that has a contract with the agency to perform those reviews.

Utilization review is performed in accordance with 42 CFR Part 456, Subpart H, that specifies the conditions of a waiver of the requirements of Subpart D for-.

All mental hospitals.

Those specified in the waiver

No waivers have been granted.

Not applicable. Inpatient services in mental

hospitals are not provided under this plan. Note: The utilization review entity will not review —

1. Inpatient hospital services in institutions for mental disease (IMD's) for clients age 65 or older; and

2. Treatment Crisis Intervention services for which coverage is limited to a maximum of 7 days.


TN No. MS-88-02

49 Revision: HCFA-PM-85-3 (BERC) OMB No. 0938-0193 May 1985 State/Territory: Nebraska Citation 4.14(d) The Medicaid agency meets the requirements of 42 CFR 456.2 42 CFR Part 456, Subpart E, for the control of 50 FR 15312 utilization of skilled nursing facility services.

Utilization and medical review are performed by a

Utilization and Quality Control Peer Review Organization designated under 42 CFR Part 462 that has a contract with the agency to perform those reviews.

Utilization review is performed in accordance with 42 CFR Part 456, Subpart H, that specifies the conditions of a waiver of the requirements of Subpart F for:

All skilled nursing facilities.

Those specified in the waiver.

No waivers have been granted.

TN No. MS-85-11 Supersedes Approval Date Sept 24 1985 Effective Date Apr 1 1985


50 Revision: HCFA-PM-85-3 (BERC) OMB No. 0938-0193 May 1985 State/Territory: Nebraska Citation 42 CFR 456.2 4.14 (e) The Medicaid agency meets the requirements of 42 50 FR 15312 CFR Part 456, Subpart F, for control of the

utilization of intermediate care facility services. Utilization review in facilities is provided through:

Facility-based review.

Direct review by personnel of the medical assistance unit of the State agency.

Personnel under contract to the medical

assistance unit of the State agency.

Utilization and Quality Control Peer Review Organizations.

Another method as described in

ATTACHMENT 4.14-A.

Two or more of the above methods. ATTACHMENT 4.14-B describes the circumstances under which each method is used.

Not applicable. Intermediate care facility services

are not provided under this plan. TN No. MS-85-11 Supersedes Approval Date Sept 24 1985 Effective Date Apr 1 1985

TN No. MS-80-38 HCFA ID: 0048P/0002P

50(a) Revision: HCFA-AT-80-38 (BPP) OMB No. 0938-0193 May 22, 1980 State/Territory: Nebraska Citation

4.14 Utilization/Quality Control (Continued)

42 CFR 438.356(e) (f) For each contract, the State must follow an open, competitive procurement process that is in accordance with State law and regulations and consistent with 45 CFR part 74 as it applies to State procurement of Medicaid services.

42 CFR 438.354 The State must ensure that an External Quality 42 CFR 438.356(b) Review Organization and its subcontractors and (d) performing the External Quality Review or External

Quality Review-related activities meets the competence and independence requirements.

Not applicable. TN No. MS-03-12 Supersedes Approval Date Nov 6 2003 Effective Date Aug 13 2003

TN No. MS-91-30

51 Revision: HCFA-PM-92-2 (HSQB) March 1992 State/Territory: Nebraska

Citation 4.15 Inspection of Care in Intermediate Care Facilities for the

Mentally Retarded, Facilities Providing Inpatient Psychiatric Services for Individuals Under 21, and Mental Hospitals

42 CFR Part The State has contracted with a Peer Review 456 Subpart Organization (PRO) to perform inspection of I, and care for: 1902(a)(31) and 1903(g) ICFs/MR; of the Act Inpatient psychiatric facilities for recipients under age 21; and Mental Hospitals. 42 CFR Part All applicable requirements of 42 CFR Part456, 456 Subpart Subpart I, are met with respect to periodic inspections A and of care and services. 1902(a)(30) of the Act Not applicable with respect to intermediate care facilities for the mentally retarded services; such services are not provided under this plan.

Not applicable with respect to services for individuals age 65 or over in institutions for mental disease; such services are not provided under this plan.

Not applicable with respect to inpatient psychiatric

services for individuals under age 21; such services are not provided under this plan.


TN No. MS-78-9

52 Revision: HCFA-AT-80-38 (BPP) May 22, 1980 State/Territory: Nebraska Citation 4.16 Relations with State Health and Vocational Rehabilitation Agencies and Title V Grantees 42 CFR 431.615(c) The Medicaid agency has cooperative arrangements with AT-78-90 State health and vocational rehabilitation agencies and with

title V grantees, that meet the requirements of 42 CFR 431.615.

ATTACHMENT 4.16-A describes the cooperative arrangements with the health and vocational rehabilitation agencies.


TN No. MS-74-1

53 Revision: HCFA-PM-95-3 (MB) May 1995 State/Territory: Nebraska

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT Citation 4.17 Liens and Adjustments or Recoveries 42 CFR 433.36(c) (a) Liens 1902(a) (18) and 1917(a) and (b) of The State imposes liens against an individual's the Act real property on account of medical assistance

paid or to be paid.

The State complies with the requirements of section 1917 (a) of the Act and regulations at 42 CFR 433.36(c)-(g) with respect to any lien imposed against the property of any individual prior to his or her death on account of medical assistance paid or to be paid on his or her behalf.

The State imposes liens on real property on

account of benefits incorrectly paid.

The State imposes TEFRA liens 1917(a)(1)(B) on real property of an individual who is an inpatient of nursing facility, ICF/MR, or other medical institution, where the individual is required to contribute toward the cost of institutional care all but a minimal amount of income required for personal needs.

The procedures by the State for determining that an institutionalized individual cannot reasonably be expected to be discharged are specified in Attachment 4.17-A. (Note: If the State indicates in its State plan that it is imposing TEFRA liens, then the State is required to determine whether an institutionalized individual is permanently institutionalized and afford these individuals notice, hearing procedures, and due process requirements.)

TN No. MS-03-01 Supersedes Approval Date Nov 6 2003 Effective Date Jan 1 2003

TN No. MS-83-01

53a Revision: HCFA-PM-95-3 (MB) May 1995

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT


Citation The State imposes liens on both real and personal

property of an individual after the individual's death. (b) Adjustments or Recoveries

The State complies with the requirements of section 1917(b) of the Act and regulations at 42 CFR 433.36(h)-(i). Adjustments or recoveries for Medicaid claims correctly paid are as follows: (1) For permanently institutionalized individuals,

adjustments or recoveries are made from the individual's estate or upon sale of the property subject to a lien imposed because of medical assistance paid on behalf of the individual for services provided in a nursing facility, ICF/MR, or other medical institution.

Adjustments or recoveries are made for all

other medical assistance paid on behalf of the individual

(2) The State determines "permanent institutional

status" of individuals under the age of 55 other than those with respect to whom it imposes liens on real property under §1917(a)(1)(B) (even if it does not impose those liens).

(3) For any individual who received medical assistance at

age 55 or older, adjustments or recoveries of payments are made from the individual's estate for nursing facility services, home and community-based services, and related hospital and prescription drug services.


TN No. MS-94-14

53b


State/Territory:

Nebraska

In addition to adjustment or recovery of payments for services listed above, payments are adjusted or recovered for other services under the State plan as listed below: All Medicaid services provided under the Nebraska Title XIX State Plan for individuals age 55 and over, except for Medicare Cost Sharing as specified at 4.17(b)(3) – Continued.

42 CFR 1396p(b)(1)(B)(ii) (3) (continued) Limitations on Estate Recovery - Medicare Cost Sharing:

(i) Medical assistance for Medicare cost sharing is protected from estate recovery for the following categories of dual eligibles: QMB, SLMB, QI, QDWI, QMB+, SLMB+. This protection extends to medical assistance for four Medicare cost sharing benefits: (Part A and B premiums, deductibles, coinsurance, co-payments) with dates of service on or after January 1,2010. The date of service for deductibles, coinsurance, and co-payments is the date the request for payment is received by the State Medicaid Agency. The date of service for premiums is the date the State Medicaid Agency paid the premium.

(ii) In addition to being a qualified dual eligible the individual must also be age 55 or over. The above protection from estate recovery for Medicare cost sharing benefits (premiums, deductibles, coinsurance, co-payments) applies to approved mandatory (i.e., nursing facility, home and community-based services, and related prescription drugs and hospital services) as well as optional Medicaid services identified in the State plan, which are applicable to the categories of duals referenced above.

TN No Supersedes Approval Date

NE 10-24 FEB 11 2011 Effective Date OCT 01 2010

TN No.

MS-06-07

53b1


State/Territory:

Nebraska

1917(b)1(c) (4) If an individual covered under a long-term care

insurance policy received benefits for which assets or resources were disregarded as provided for in Attachment 2.6-A, Supplement 8c (State Long-Term Care Insurance Partnership), the State does not seek adjustment or recovery from the individuals estate for the amount of assets or resources disregarded.

TN No. Supersedes Approval Date

NE 10-24 FEB 11 2011 Effective Date

TN No. OCT 01 2010

New page

53c Revision: HCFA-PM-95-3 (MB) May 1995



Citation (c) Adjustments or Recoveries: Limitations

The State complies with the requirements of section 1917(b)(2) of the Act and regulations at 42 CFR §433.36(h) - (i). (1) Adjustment or recovery of medical assistance

correctly paid will be made only after the death of the individual's surviving spouse, and only when the individual has no surviving child who is either under age 21, blind, or disabled.

(2) With respect to liens on the home of any

individual who the State determines is permanently institutionalized and who must as a condition of receiving services in the institution apply their income to the cost of care, the State will not seek adjustment or recovery of medical assistance correctly paid on behalf of the individual until such time as none of the following individuals are residing in the individual's home:

(a) a sibling of the-individual (who was residing

in the individual's home for at least one year immediately before the date that the individual was institutionalized), or

(b) a child of the individual (who was residing in

the individual's home for at least two years immediately before the date that the individual was institutionalized) who establishes to the satisfaction of the State that the care the child provided permitted the individual to reside at home rather than become institutionalized.


TN No. New Page

53d Revision: HCFA-PM-95-3 (MB) May 1995



Citation (3) No money payments under another program are reduced as a means of adjusting or recovering Medicaid claims incorrectly paid. (d) ATTACHMENT 4.17-A

(1) Specifies the procedures for determining that an institutionalized individual cannot reasonably be expected to be discharged from the medical institution and return home. The description of the procedure meets the requirements of 42 CFR 433.36(d).

(2) Specifies the criteria by which a son or a

daughter can establish that he or she has been providing care, as specified under 42 CFR 433.36(f).

(3) Defines the following terms:

• estate (at a minimum, estate as defined under State probate law). Except for the grandfathered States listed in section 4.17(b)(3), if the State provides a disregard for assets or resources for any individual who received or is entitled to receive benefits under a long term care insurance policy, the definition of estate must include all real, personal property, and assets of an individual (including any property or assets in which the individual had any legal title or interest at the time of death to the extent of the interest and also including the assets conveyed through devices such as joint tenancy, life estate, living trust, or other arrangement),


TN No. New Page

53e Revision: HCFA-PM-95-3 (MB) May 1995


State/Territory: Nebraska Citation

• individual's home, • equity interest in the home, • residing in the home for at least 1 or 2

years, • on a continuous basis, • discharge from the medical institution and

return home, and • lawfully residing.

(4) Describes the standards and procedures for

waiving estate recovery when it would cause undue hardship.

(5) Defines when adjustment or recovery is not cost-

effective. Defines cost-effective and includes methodology or thresholds used to determine cost- effectiveness.

(6) Describes collection procedures. Includes

advance notice requirements, specifies the method for applying for a waiver, hearing and appeals procedures, and the time frames involved.


TN No. New Page

54 Revision: HCFA-PM-91-4 (BPD) OMB No. 0938- August 1991 State/Territory: Nebraska Citation 4.18 Recipient Cost Sharing and Similar Charges 42 CFR 447.51 (a) Unless a waiver under 42 CFR 431.55(g) applies, deductibles, through 447.58 coinsurance rates, and copayments do not exceed the maximum allowable charges under 42 CFR 447.54. 1916(a) and (b) (b) Except as specified in items 4.18(b)(4), (5), and (6) below, of the Act with respect to individuals covered as categorically needy

or as qualified Medicare beneficiaries (as defined in section 1905(p)(1) of the Act) under the plan:

(1) No enrollment fee, premium, or similar charge is imposed under the plan

(2) No deductible, coinsurance, copayment or similar charge is

imposed under the plan for the following:

(i) Services to individuals under age 18, or under--

Age 19 Age 20 Age 21

Reasonable categories of individuals who are age 18 or older, but under age 21, to whom charges apply are listed below, if applicable.

Individuals age 19 and 20 who are eligible under the - 1. ADC Program; 2. AABD Program; 3. Refugee Resettlement Program; or 4. Ribicoff Program.

(ii) Services to pregnant women related to the pregnancy or any other medical condition that may complicate the pregnancy.

TN No. MS-94-2 Supersedes Approval Date Apr 14 1994 Effective Date Apr 1 1994


55 Revision: HCFA-PM-91-4 (BPP) OMB No.: 0938 August 1991 State/Territory: Nebraska Citation 4 .18(b) (2) (Continued) 42 CFR 447.51 (iii) All services furnished to pregnant women. through 447.58 Not applicable. Charges apply for services to pregnant women unrelated to the pregnancy.

(iv) Services furnished to any individual who is an inpatient in a hospital, long-term care facility, or other medical institution, if the individual is required, as a condition of receiving services in the institution, to spend for medical care costs all but a minimal amount of his or her income required for personal needs.

(v) Emergency services if the services meet the

requirements in 42 CFR 447.53(b)(4). (vi) Family planning services and supplies furnished to

individuals of childbearing age. (vii) Services furnished by a managed care organization,

health insuring organization, prepaid inpatient health plan, or prepaid ambulatory health plan in which the individual is enrolled, unless they meet the requirements of 42 CFR 447.60.

42 CFR 438.108 Managed care enrollees charged 42 CFR 447.60 deductibles, coinsurance rates, and copayments in an amount equal to the State Plan service cost sharing.

Managed care enrollees are not charged deductibles, coinsurance rates, and copayments.

1916 of the Act, (viii) Services furnished to an individual receiving P.L. 99-272, hospice care, as defined in section 1905(o) (Section 9505) of the Act.


TN No. MS-94-2

56 Revision: HCFA-AT-91-4 (BPD) OMB No.: 0938- August 1991 State/Territory: Nebraska Citation 4.18(b) (Continued) 42 CFR 447.51 (3) Unless a waiver under 42 CFR 431.55(g) through applies, nominal deductible, coinsurance, 447.48 copayment, or similar charges are imposed for services that are not excluded from such charges under item (b)(2) above. Not applicable. No such charges are imposed.

(i) For any service, no more than one type of charge is imposed.

(ii) Charges apply to services furnished to the

following age groups:

18 or older

19 or older

20 or older

21 or older

Charges apply to services furnished to the following reasonable categories of individuals listed below who are 18 years of age or older but under age 21.

Individuals age 19 and 20 who are eligible under the -

1. ADC Program; 2. AABD Program; 3. Refugee Resettlement Program; or 4. Ribicoff Program.


TN No. MS-91-24 HCFA ID: 0048P/0002P

56a Revision: HCFA-AT-91-4 (BPD) OMB No. 0938- August 1991 State/Territory: Nebraska Citation 4.18(b)(3) (Continued) 42 CFR 447.51 (iii) For the categorically needy and qualified through 447.58 Medicare beneficiaries, ATTACHMENT

4.18-A specifies the:

(A) Service(s) for which a charge(s) is applied; (B) Nature of the charge imposed on each

service; (C) Amount(s) of and basis for determining the

charge(s); (D) Method used to collect the charge(s); (E) Basis for determining whether an individual

is unable to pay the charge and the means by which such an individual is identified to providers;

(F) Procedures for implementing and enforcing

the exclusions from cost sharing contained in 42 CFR 447.53(b); and

(G) Cumulative maximum that applies to all

deductible, coinsurance or copayment charges imposed on a specified time period.

Not applicable. There is no maximum.



56b Revision: HCFA-PM-91-4 (BPD) OMB No. 0938- August 1991 State/Territory: Nebraska Citation 1916(c) of the Act 4.18(b)(4) A monthly premium is imposed on pregnant women

and infants who are covered under section 1902(a)(10)(A)(ii)(IX) of the Act and whose income equals or exceeds 150 percent of the Federal poverty level applicable to a family of the size involved. The requirements of section 1916(c) of the Act are met. ATTACHMENT 4.18-D specifies the method the State uses for determining the premium and the criteria for determining what constitutes undue hardship for waiving payment of premiums by recipients.

1902(a)(52) 4.18(b)(5) For families receiving extended benefits during a and 1925(b) second 6-month period under section 1925 of the of the Act Act, a monthly premium is imposed in accordance

with sections 1925(b)(4) and (5) of the Act.

1916(d) of the Act 4.18(b)(6) A monthly premium, set on a sliding scale, imposed on qualified disabled and working individuals who are covered under section 1902(a)(10)(E)(ii) of the Act and whose income exceeds 150 percent (but does not exceed 200 percent) of the Federal poverty level applicable to a family of the size involved. The requirements of section 1916(d) of the Act are met. ATTACHMENT 4.18-E specifies the method and standards the State uses for determining the premium.



56c Revision: HCFA-AT-91-4 (BPD) OMB No. 0938- August 1991 State/Territory: Nebraska Citation 4.18(c) Individuals are covered as medically needy under the plan. 42 CFR 447.51 (1) An enrollment fee, premium or similar through 447.58 charge is imposed. ATTACHMENT

4.18-B specifies the amount of and liability period for such charges subject to the maximum allowable charges in 42 CFR 447.52(b) and defines the State's policy regarding the effect on recipients of non-payment of the enrollment fee, premium, or similar charge.

447.51 through (2) No deductible, coinsurance, copayment, 447.58 or similar charge is imposed under the

plan for the following:

(i) Services to individuals under age 18,or under—

Age 19

Age 20

Age 21

Reasonable categories of individuals who are age 18, but under age 21, to whom charges apply are listed below, if applicable:

Individuals age 19 and 20 who are eligible under the - 1. ADC Program; 2. AABD Program; 3. Refugee Resettlement Program; or 4. Ribicoff Program.



56d Revision: HCFA-AT-91-4 (BPD) OMB No. 0938- August 1991 State/Territory: Nebraska Citation 4.18 (c)(2) (Continued) 42 CFR 447.51 (ii) Services to pregnant women related to the through pregnancy or any other medical condition 447.58 that may complicate the pregnancy. (iii) All services furnished to pregnant women.

Not applicable. Charges apply for services to pregnant women unrelated to the pregnancy.

(iv) Services furnished to any individual who is an

inpatient in a hospital, long-term care facility, or other medical institution, if the individual is required, as a condition of receiving services in the institution, to spend for medical care costs all but a minimal amount of his income required for personal needs.

(v) Emergency services if the services meet the

requirements in 42 CFR 447.53(b)(4). (vi) Family planning services and supplies furnished

to individuals of childbearing age. 1916 of the Act, (vii) Services furnished to an individual P.L. 99-272 receiving hospice care, as defined (Section 9505) in section 1905(o) of the Act. 447.51 through (viii) Services provided by a health 447.58 maintenance organization (HMO) to enrolled individuals.

Not applicable. No such charges are imposed.



56e Revision: HCFA-PM-91-4 (BPD) OMB No. 0938- August 1991 State/Territory: Nebraska Citation

4.18 (c) (3) Unless a waiver under 42 CFR 431.55(g)applies, nominal deductible, coinsurance, copayment, or similar charges are imposed on services that are not excluded from such charges under item (b)(2) above.

Not applicable. No such charges

are imposed.

(i) For any service, no more than one type of charge is imposed.

(ii) Charges apply to services furnished to the following age group:

1. 18 or older 2. 19 or older 3. 20 or older 4. 21 or older

Reasonable categories of individuals

who are 18 years of age, but under 21, to whom charges apply are listed below, if applicable.

Individuals age 19 and 20 who are eligible under the -

1. ADC Program; 2. AABD Program;

3. Refugee Resettlement Program; or 4. Ribicoff Program.



56f

Revision: HCFA-PM-91-4 (BPD) OMB No. 0938- August 1991 State/Territory: Nebraska Citation 4.18(c)(3) (Continued) 447.51 through (iii) For the medically needy, and other 447.58 optional groups, ATTACHMENT 4.18C specifies the:

(A) Service(s) for which charge(s) is applied;

(B) Nature of the charge imposed on each service;

(C) Amount(s) of and basis for

determining the charge(s); (D) Method used to collect the charge(s); (E) Basis for determining whether an

individual is unable to pay the charge(s) and the means by which such an individual is identified to providers;

(F) Procedures for implementing and

enforcing the exclusions from cost sharing contained in 42 CFR 447.53(b); and

(G) Cumulative maximum that applies to

all deductible, coinsurance, or copayment charges imposed on a family during a specified time period.

Not applicable. There is no

maximum. TN No. MS-94-2 Supersedes Approval Date Apr 14 1994 Effective Date Apr 1 1994


57 Revision: HCFA-PM-91-4 (BPD) OMB No. 0938- August 1991 State/Territory: Nebraska Citation 4.19 Payment for Services 42 CFR 447.252 (a) The Medicaid agency meets the requirements of 1902(a)(13) 42 CFR Part 447, Subpart C, and sections and 1923 of 1902(a)(13) and 1923 of the Act with respect to the Act payment for inpatient hospital services.

ATTACHMENT 4.19-A describes the methods and standards used to determine rates for payment for inpatient hospital services.

Inappropriate level of care days are covered and are paid under the State plan at lower rates than other inpatient hospital services, reflecting the level of care actually received, in a manner consistent with section 1861(v)(1)(G) of the Act.

Inappropriate level of care days are not covered. TN No. MS-91-24 Supersedes Approval Date Jan 20 1992 Effective Date Nov 1 1991

TN No. MS-87-11

58 Revision: HCFA-PM-93-6 (MB) OMB No. 0938- August 1993 State/Territory: Nebraska Citation 42 CFR 447.201 4.19(b) In addition to the services specified in paragraphs 42 CFR 447.302 4.19(a), (d), (k), (l), and (m),the Medicaid agency 52 FR 28648 meets the following requirements: 1902(a)(13)(E) 1903(a)(1) and (1) Section 1902(a)(13)(E) of the Act regarding (n), 1920, and payment for services furnished by Federally 1926 of the Act qualified health centers (FQHCs) under section

1905(a)(2)(C) of the Act. The agency meets the requirements of section 6303 of the State Medicaid Manual (HCFA-Pub. 45-6) regarding payment for FQHC services. ATTACHMENT 4.19-B describes the method of payment and how the agency determines the reasonable costs of the services (for example, cost-reports, cost or budget reviews, or sample surveys).

(2) Sections 1902(a)(13)(E) and 1926 of the Act, and

42 CFR Part 447, Subpart D, with respect to payment for all other types of ambulatory services provided by rural health clinics under the plan.

ATTACHMENT 4.19-B describes the methods and standards used for the payment of each of these services except for inpatient hospital, nursing facility services and services in intermediate care facilities for the mentally retarded that are described in other attachments.

1902(a)(10) and SUPPLEMENT 1 to ATTACHMENT 4.19-B describes 1902(a)(30) of general methods and standards used for establishing the Act payment for Medicare Part A and B deductible/coinsurance.

TN No. MS-93-14 Supersedes Approval Date Sept 24 1993 Effective Date Jul 1 1993

TN No. MS-92-1

59 Revision: HCFA-AT-80-38 (BPP) May 22, 1980 State/Territory: Nebraska Citation 4.19(c) Payment is made to reserve a bed during a recipient’s 42 CFR 447.40 temporary absence from an inpatient facility. AT-78-90

Yes. The State’s policy is described in ATTACHMENT 4.19-C No. TN No. MS-80-38 Supersedes Approval Date Apr 4 1977 Effective Date Jul 1 1977

TN No. MS-78-2

60 Revision: HCFA-AT-87-9 (BERC) OMB No. 0938-0193 August 1987 State/Territory: Nebraska Citation 4.19(d) 42 CFR 447.252 (1) The Medicaid agency meets the requirements of 42 CFR Part 47 FR 47964 447, Subpart C. with respect to payments for skilled nursing 48 FR 56046 and intermediate care facility services. 42 CFR 447.280 47 FR 31518 ATTACHMENT 4.19-D describes the methods and standards 52 FR 28141 used to determine rates for payment for skilled nursing 4.19 (d) and intermediate care facility services.

(2) The Medicaid agency provides payment for routine skilled nursing

facility services furnished by a swing-bed hospital.

At the average rate per patient day paid to SNFs for routine services furnished during the previous calendar year.

At a rate established by the State, which meets the

requirements of 42 CFR Part 447, Subpart C, as applicable.

Not applicable. The agency does not provide payment for SNF services to a swing-bed hospital.

(3) The Medicaid agency provides payment for routine intermediate

care facility services furnished by a swing-bed hospital.

At the average rate per patient day paid to ICFs, other than ICFs for the mentally retarded, for routine services furnished during the previous calendar year.

At a rate established by the State, which meets the

requirements of 42 CFR Part 447, Subpart C, as applicable.

Not applicable. The agency does not provide payment for ICF services to a swing-bed hospital.

(4) Section 4.19(d)(1) of this plan is not applicable with respect to

intermediate care facility services; such services are not provided under this State plan.

TN No. MS-87-17 Supersedes Approval Date Oct 4 1988 Effective Date Oct 1 1987


61 Revision: HCFA-AT-80-38 (BPP) May 22, 1980 State/Territory: Nebraska Citation 4.19(e) The Medicaid agency meets all requirements 42 CFR 447.45(c) of 42 CFR 447.45 for timely payment of AT-79-50 claims.

ATTACHMENT 4.19-E specifies, for each type of service, the definition of a claim for purposes of meeting these requirements.

TN No. MS-80-38 Supersedes Approval Date Oct 10 1979 Effective Date Aug 23 1979

TN No. MS-79-10

62 Revision: HCFA-PM-87-4 (BERC) OMB No. 0938-0193 March 1987 State/Territory: Nebraska Citation 4.19 (f) The Medicaid agency limits participation to 42 CFR 447.15 providers who meet the requirements of AT-78-90 42 CFR 447.15. AT-80-34 48 FR 5730 No provider participating under this plan may

deny services to any individual eligible under the plan on account of the individual's inability to pay a cost sharing amount imposed by the plan in accordance with 42 CFR 431.55(g) and 447.53. This service guarantee does not apply to an individual who is able to pay, nor does an individual's inability to pay eliminate his or her liability for the cost sharing change.



63 Revision: HCFA-AT-80-38 (BPP) May 22, 1980 State/Territory: Nebraska Citation 4.19(g) The Medicaid agency assures appropriate audit 42 CFR 447.201 of records when payment is based on costs of 42 CFR 447.202 services or on a fee plus cost of materials. AT-78-90 TN No. MS-80-38 Supersedes Approval Date Oct 19 1979 Effective Date Aug 6 1979

TN No. MS-79-8

64 Revision: HCFA-AT-80-60 (BPP) August 12, 1980 State/Territory: Nebraska Citation 4.19(h) The Medicaid agency meets the requirements 42 CFR 447.201 of 42 CFR 447.203 for documentation and 42 CFR 447.203 availability of payment rates. AT-78-90 TN No. 80-60 & 80-38 Supersedes Approval Date Oct 19 1979 Effective Date Aug 6 1979

TN No. MS-79-8

65

Revision: HCFA-AT-80-38 (BPP) May 22, 1980 State/Territory: Nebraska Citation 4.19(i) The Medicaid agency's payments are sufficient 42 CFR 447.201 to enlist enough providers so that services under 42 CFR 447.204 the plan are available to recipients at least to the AT-78-90 extent that those services are available to the general peculation. TN No. MS-80-38 Supersedes Approval Date Oct 19 1979 Effective Date Aug 6 1979

TN No. MS-79-8

66 Revision: HCFA-PM-91-4 (BPD) OMB No. 0938- August 1991 State/Territory: Nebraska Citation 42 CFR 4.19 (j) The Medicaid agency meets the requirements of 42 447.201 CFR 447.205 for public notice of any changes in and 447.205 Statewide method or standards for setting payment rates. 1903(v) of the (k) The Medicaid agency meets the requirements Act of section 1903(v) of the Act with respect to

payment for medical assistance furnished to an alien who is not lawfully admitted for permanent residence or otherwise permanently residing in the United States under color of law. Payment is made only for care and services that are necessary for the treatment of an emergency medical condition, as defined in section 1903(v) of the Act.


TN No. MS-91-16

66(a) Revision: HCFA-PM-92-7 (MB) October 1992 State/Territory: Nebraska Citation 1903(i)(14) 4.19 (l) The Medicaid agency meets the requirements of the Act of section 1903(i)(14) of the Act with respect to payment for physician services furnished to children under 21 and pregnant women. Payment for physician services furnished by a physician to a child or a pregnant woman is made only to physicians who meet one of the requirements listed under this section of the Act. TN No. MS-92-22 Supersedes Approval Date Mar 1 1993 Effective Date Oct 1 1992

TN No. New Page

66(b) Revision: HCFA-PM-94-B (MB) October 1994 State/Territory:

Nebraska

Citation

4.19(m)

Medicaid Reimbursement for Administration of Vaccines under the

Pediatric Immunization Program

1928(c)(2) (i) A provider may impose a charge for the administration of (C)(ii) of a qualified pediatric vaccine as stated in 1928(c)(2)(C) of the Act. (ii) of the Act. Within this overall provision, Medicaid the Act

reimbursement to providers will be administered as follows. (ii) The State:

sets a payment rate at the level of the regional maximum established by the DHHS Secretary.

is a Universal Purchase State and sets a payment rate at the level

of the regional maximum established in accordance with State law.

sets a payment rate below the level of the regional maximum established by the DHHS Secretary.

is a Universal Purchase State and sets a payment rate below the

level of the regional maximum established by the Universal Purchase State.

The State pays the following rate for the administration of a

vaccine: $10.50

1926 of (iii) Medicaid beneficiary access to immunizations is assured the Act through the following methodology:

The State will compare -

a. The number of Medicaid pediatric practitioners (including practitioners

listed in section 1926(a)(4)(B) of the Act) who are Medicaid-enrolled providers and who have submitted pediatric immunization claims; and

b. The total number of pediatric practitioners providing immunizations to

children.

The Medicaid-enrolled providers must have at least one Medicaid pediatric immunization claim per month or an average of 12 claims per year.

TN No. Supersedes Approval Date

NE 11-12 NOV 02 2011 Effective Date

TN No.JUL 01 2011

MS-08-04

67 Revision: HCFA-AT-80-38 (BPP) May 22, 1980 State/Territory: Nebraska Citation 4.20 Direct Payments to Certain Recipients for Physicians' or Dentists' Services 42 CFR 447.25(b) Direct payments are made to certain recipients as specified AT-78-90 by, and in accordance with, the requirements of 42 CFR

447.25. Yes, for physicians' services dentists' services

ATTACHMENT 4.20-A specifies the conditions under which such payments are made.

Not applicable. No direct payments are made to recipients.

TN No. MS-78-2 Supersedes Approval Date Feb 28 1978 Effective Date Jan 1 1978

TN No. MS-77-2

68 Revision: HCFA-AT-81-34 (BPP) State/Territory: Nebraska Citation 4.21 Prohibition Against Reassignment of Provider Claims 42 CFR 447.10(c) Payment for Medicaid services furnished by any AT-78-90 provider under this plan is made only in accordance 46 FR 42699 with the requirements of 42 CFR 447.10. TN No. MS-81-10 Supersedes Approval Date Dec 10 1981 Effective Date Oct 1 1981

TN No. MS-75-1

69 Revision: HCFA-PM-94-1 (MB) February 1994 State/Territory: Nebraska Citation 4.22 Third Party Liability 42 CFR 433.137 (a) The Medicaid agency meets all requirements of: 1902(a)(25)(H) and (I) 1. 42 CFR 433.138 and 433.139. of the Act 2. 42 CFR 433.145 through 433.148. 3. 42 CFR 433.151 through 433.154. 4. Sections 1902(a)(25)(H) and (I) of the Act. 42 CFR 433.138(f) (b) ATTACHMENT 4.22-A – (1) Specifies the frequency with which the data exchanges required in §433.138(d)(1), (d)(3) and (d)(4) and the diagnosis and trauma code edits required in §433.138(e) are conducted; 42 CFR 433.138(g)(1)(ii) (2) Describes the methods the agency uses for and (2)(ii) meeting the followup requirements contained in §433.138(g)(1)(i) and (g)(2)(i); 42 CFR 433.138(g)(3)(i) (3) Describes the methods the agency uses for and (iii) following up on information obtained

through the State motor vehicle accident report file data exchange required under §433.138(d)(4)(ii) and specifies the time frames for incorporation into the eligibility case file and into its third party data base and third party recovery unit of all information obtained through the followup that identifies legally liable third party resources; and

42 CFR 433.138(g)(4)(i) (4) Describes the methods the agency uses for through (iii) following up on paid claims identified under

§433.138(e) (methods include a procedure for periodically identifying those trauma codes that yield the highest third party collections and giving priority to following up on those codes) and specifies the time frames for incorporation into the eligibility case file and into its third party data base and third party recovery unit of all information obtained through the followup that identifies legally liable third party resources.

TN No. MS-94-12 Supersedes Approval Date Oct 19 1994 Effective Date Jul 1 1994

TN No. MS-90-11

69a Revision: HCFA-PM-94-1 (MB) February 1994 State/Territory: Nebraska Citation 42 CFR 433.139(b)(3) (c) Providers are required to bill liable third parties (ii) (A) when services covered under the plan are furnished to an individual on whose behalf child support enforcement is being carried out by the State IV-D agency. (d) ATTACHMENT 4.22-B specifies the following: 42 CFR 433.139(b)(3) (1) The method used in determining a (ii)(C) provider's compliance with the third party billing requirements at §433.139(b)(3)(ii)(C). 42 CFR 433.139(f)(2) (2) The threshold amount or other guideline used in determining whether to seek

recovery of reimbursement from a liable third party, or the process by which the agency determines that seeking recovery of reimbursement would not be cost effective.

42 CFR 433.139(f)(3) (3) The dollar amount or time period the

State uses to accumulate billings from a particular liable third party in making the decision to seek recovery of reimbursement.

42 CFR 447.20 (e) The Medicaid agency ensures that the provider furnishing a service for which a third party is liable follows the restrictions specified in 42 CFR 447.20. TN No. MS-94-12 Supersedes Approval Date Oct 19 1994 Effective Date Jul 1 1994

TN No. MS-90-11

70 Revision: HCFA-PM-94-1 (MB) February 1994 State/Territory: Nebraska Citation

4.22 (continued)

42 CFR 433.151(a) (f) The Medicaid agency has written cooperative agreements for the enforcement of rights to and

collection of third party benefits assigned to the State as a condition of eligibility for medical assistance with the following: (Check as appropriate.)

State title IV-D agency. The requirements of 42

CFR 433.152(b) are met.

Other appropriate State agency(s)

Other appropriate agency(s) of another State

Courts and law enforcement officials. 1902(a)(60) of the Act (g) The Medicaid agency assures that the State has in effect the laws relating to medical child support under section 1908 of the Act. 1906 of the Act (h) The Medicaid agency specifies the guidelines used in

determining the cost effectiveness of an employer- based group health plan by selecting one of the following.

The Secretary's method as provided in the State Medicaid Manual, Section 3910.

The State provides methods for determining

cost effectiveness on ATTACHMENT 4.22-C.

TN No. MS-94-12 Supersedes Approval Date Oct 191994 Effective Date Jul 1 1994

TN No. MS-91-14

71 Revision: HCFA-AT-84-2 (BERC) OMB No. 0938-0193 01-84 State/Territory: Nebraska Citation 4.23 Use of Contracts 42 CFR Part 434.4 The Medicaid agency has contracts of the type(s) listed 48 FR 54013 in 42 CFR Part 434. All contracts meet the requirements of 42CFR Part 434. Not applicable. The State has such no contracts. TN No. MS-84-2 Supersedes Approval Date Feb 14 1984 Effective Date Jan 1 1984

TN No. MS-80-5

72 Revision: HCFA-PM-94-2 (BPD) April 1994 State/Territory: Nebraska Citation 4.24 Standards for Payments for Nursing Facility and Intermediate Care Facility for the Mentally Retarded Services 42 CFR 442.10 With respect to nursing facilities and intermediate care and 442.100 facilities for the mentally retarded, all applicable AT-78-90 requirements of 42 CFR Part 442, Subparts B and C are AT-79-18 met. AT-80-25 AT-80-34 Not Applicable to intermediate care facilities for the 52 FR 32544 mentally retarded; such services are not provided P.L, 100-203 under this plan. (Sec.4211) 54 FR 5316 56 FR 48826

TN No. MS-94-4 Supersedes Approval Date Apr 4 1994 Effective Date Jan 1 1994

TN No. MS-91-1

73 Revision: HCFA-AT-80-38 (BPP) May 22, 1980 State/Territory: Nebraska Citation 4.25 Program for Licensing Administrators of Nursing Homes 42 CFR 431.702 The State has a program that, except with respect to AT-78-90 Christian Science sanatoria, meets the requirements of 42

CFR Part 431,Subpart N, for the licensing of nursing home administrators.


TN No. N/A

74 Revision: HCFA-PM (MB) State/Territory: Nebraska Citation

4.26 Drug Utilization Review Programs

1927(g) A. 1. The Medicaid agency meets the requirements of Section 42 CFR 456.700 1927(g) of the Act for a drug use review (DUR) program

for outpatient drug claims.

1927(g)(1)(A) 2. The DUR program assures that prescriptions for outpatient drugs are:

- Appropriate - Medically necessary - are not likely to result in adverse medical results

1927(g)(1)(a) B. The DUR program is designed to educate physicians 42 CFR 456.705(b) and pharmacist to identify and reduce the frequency and 456.709(b) of patterns of fraud, abuse, gross overuse, or

inappropriate or medically unnecessary care among physicians, pharmacists, and patients or associated with specific drugs as well as:

- Potential and actual adverse drug reactions - Therapeutic appropriateness - Overutilization and underutilization - Appropriate use of generic products - Drug disease contraindications - Drug-drug interactions - Incorrect drug dosage or duration of drug

treatment - Drug-allergy interactions - Clinical abuse/misuse

1927(g)(1)(B) C. The DUR program shall assess data use against 42 CFR 456.703 predetermined standards whose source materials (d) and (f) for their development are consistent with peer-

reviewed medical literature which has been critically reviewed by unbiased independent experts and the following compendia.

- American Hospital Formulary Service Drug Information - United States Pharmacopeia-Drug Information - American Medical Association Drug Evaluations

TN No. MS-93-10 Supersedes Approval Date May 3 1993 Effective Date Apr 1 1993

TN No. MS-92-20

74a Revision: HCFA-PM- (MB) State/Territory: Nebraska Citation 1927(g)(1)(D) D. DUR is not required for drugs dispensed to residents of 42 CFR 456.703(b) nursing facilities that are in compliance with drug regimen

review procedures set forth in 42 CFR 483.60. The State has never- the-less chosen to include nursing home drugs in:

Prospective DUR Retrospective DUR.

1927(g)(2)(A) E. 1. The DUR program includes prospective review of 42 CFR 456.705(b) drug therapy at the point of sale or point of distribution before each prescription is filled or delivered to the Medicaid recipient. 1927(g)(2)(A)(i) 2. Prospective DUR includes screening each 42 CFR 456.705(b), (1)-(7) prescription filled or delivered to an individual receiving benefits for potential drug therapy

problems due to:

- Therapeutic duplication - Drug-disease contraindications - Drug-drug interactions - Drug-interactions with non-prescription or over-the-

counter drugs - Incorrect drug dosage or duration of drug treatment - Drug allergy interactions - Clinical abuse/misuse

1927(g)(2)(A)(ii) 3. Prospective DUR includes counseling for Medicaid 42 CFR 456.705 (c) recipients based on standards established by State and (d) law and maintenance of patient profiles. 1927(g)(2)(B) F. 1. The DUR program includes retrospective DUR 42 CFR 456.709(a) through its mechanized drug claims processing

and information retrieval system or otherwise which undertakes ongoing periodic examination of claims data and other records to identify: - Patterns of fraud and abuse - Gross overuse - Inappropriate or medically unnecessary care among physicians, pharmacists, Medicaid recipients, or associated with specific drugs or groups of drugs.


TN No. MS-92-20

74b Revision: HCFA-PM- (MB) State/Territory: Nebraska Citation 927(g)(2)(C) F. 2. The DUR program assesses data on drug use against explicit 42 CFR 456.709(b) predetermined standards including but not limited to monitoring for:

- Therapeutic appropriateness - Overutilization and underutilization - Appropriate use of generic products - Therapeutic duplication - Drug-disease contraindications - Drug-drug interactions - Incorrect drug dosage/duration of drug treatment - Clinical abuse/misuse

1927(g)(2)(D) 3. The DUR program through its State DUR Board, using 42 CFR 456.711 data provided by the Board, provides for active and ongoing educational outreach programs to educate practitioners on common drug therapy problems to improve prescribing and dispensing practices. 1927(g)(3)(A) G. 1. The DUR program has established a State DUR Board either: 42 CFR 456.716(a)

Directly, or Under contract with a private organization

1927(g)(3)(B) 2. The DUR Board membership includes health professionals 42 CFR 456.716 (one-third licensed actively practicing pharmacists and one- (A) AND (B) third but no more than 51 percent licensed and actively practicing physicians)with knowledge and experience in one or more of the following:

- Clinically appropriate prescribing of covered outpatient drugs. - Clinically appropriate dispensing and monitoring of covered

outpatient drugs. - Drug use review, evaluation and intervention. - Medical quality assurance.

927(g)(3)(C) 3. The activities of the DUR Board include: 42 CFR 456.716(d)

- Retrospective DUR - Application of Standards as defined in section 1927(g)(2)(C),

and - Ongoing interventions for physicians and pharmacists

targeted toward therapy problems or individuals identified in the course of retrospective DUR.


TN No. MS-92-20

74c Revision: HCFA-PM- (MB) OMB No. State/Territory: Nebraska Citation 1927(g)(3)(C) G. 4. The interventions include in appropriate instances: 42 CFR 456.711 (a)-(d) - Information dissemination - Written, oral, and electronic reminders - Face-to-Face discussions - Intensified monitoring/review of prescribers/dispensers 1927(g)(3)(D) H. The State assures that it will prepare and submit an 42 CFR 456.712 annual report to the Secretary, which incorporates (A) and (B) a report from the State DUR Board, and that the State will adhere to the plans, steps, procedures as described in the report. 1927(h)(1) I. 1. The State establishes, as its principal means of 42 CFR 456.722 processing claims for covered outpatient drugs under this title, a point-of-sale electronic claims management system to perform on-line:

- real time eligibility verification - claims data capture - adjudication of claims - assistance to pharmacists, etc. applying for and

receiving payment.

1927(g)(2)(A)(i) 2. Prospective DUR is performed using an electronic 42 CFR 456.705(b) point of sale drug claims processing system. 1927(j)(2) 42 CFR 456.703(c) J. Hospitals which dispense covered outpatient drugs are exempted from the ,drug utilization review requirements of this section when facilities use drug formulary systems and bill the Medicaid program no more than the hospital's purchasing cost for such covered outpatient drugs. TN No. MS-93-10 Supersedes Approval Date May 3 1993 Effective Date Apr 1 1993

TN No. New Page

74d Revision: HCFA-PM- (MB) OMB No. State/Territory: Nebraska Citation 1902(a)(85) and Section 1004 of the Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities Act (SUPPORT Act)

Claim Review Limitations • Prospective safety edits on opioid prescriptions

to address days’ supply, early refills, duplicate fills and quantity limitations for clinical appropriateness.

• Prospective safety edits on maximum daily morphine milligram equivalents (MME) on opioids prescriptions to limit the daily morphine milligram equivalent (as recommended by clinical guidelines).

• Retrospective reviews on opioid prescriptions exceeding these above limitations on an ongoing basis.

• Retrospective reviews on concurrent utilization of opioids and benzodiazepines as well as opioids and antipsychotics on an ongoing periodic basis.

Programs to monitor antipsychotic medications to children: Antipsychotic agents are reviewed for appropriateness for all children including foster children based on approved indications and clinical guidelines.

Fraud and abuse identification: The DUR program has established a process that identifies potential fraud or abuse of controlled substances by enrolled individuals, health care providers and pharmacies.

TN No. New Page Supersedes Approval Date March 2, 2020 Effective Date October 1, 2019

TN No. __________

75 Revision: HCFA-AT-80-38 (BPP) May 22, 1980 State/Territory: Nebraska Citation 4.27 Disclosure of Survey information and Provider or Contractor Evaluation 42 CFR 431.115(c) AT-78-90 The Medicaid agency has established procedures for AT-79-74 disclosing pertinent findings obtained from surveys and provider and contractor evaluations that meet all the requirements in 42 CFR 431.115. TN No. MS-79-18 Supersedes Approval Date Jan 29 1980 Effective Date Oct 15 1979

TN No. MS-76-15

76 Revision: HCFA-PM-93-1 (BPD) January 1993 State/Territory: Nebraska Citation 4.28 Appeals Process 42 CFR 431.152; (a) The Medicaid agency has established appeals AT-79-18 procedures for NFs as specified in 42 CFR 52 FR 22444; 431.153 and 431.154. Secs. 1902(a)(28)(D)(i) and 1919(e)(7) of (b) The State provides an appeals system that meets the Act; P.L. the requirements of 42 CFR 431 Subpart E, 42 100-203 (Sec. 4211(c)) CFR 483.12, and 42 CFR 483 Subpart E for

residents who wish to appeal a notice of intent to transfer or discharge from a NF and for individuals adversely affected by the preadmission and annual resident review requirements of 42 CFR 483 Subpart C.


TN No. MS-88-14

77 Revision: HCFA-PM-99-3 (CMSO) June 1999 State/Territory: Nebraska

Citation 4.29 Conflict of Interest Provisions 1902(a)(4)(C) of the The Medicaid agency meets the requirements of Social Security Act Section 1902(a)(4)(C) of the Act concerning the P.L. 105-33 prohibition against acts, with respect to any activity under the plan, that is prohibited by section 207 or 208 of Title 18, United States Code. 1902(a)(4)(D) of the The Medicaid agency meets the requirements of Social Security Act 1902(a)(4)(D)of the Act concerning the P.L. 105-33 safeguards against conflicts of interest that are at 1932(d)(3) least as stringent as the safeguards that apply 42 CFR 438.58 under section 27 of the Office of Federal Procurement Policy Act (41 U.S.C. 423). TN No. MS-03-12 Supersedes Approval Date Nov 6 2003 Effective Date Aug 13 2003

TN No. MS-01-07

78 Revision: HCFA-PM-87-14 (BERC) OMB No. 0938-0193 October 1987 State/Territory: Nebraska

Citation 4.30 Exclusion of Providers and Suspension of Practitioners and Other Individuals 42 CFR 1002.203 (a) All requirements of 42 CFR Part 1002, Subpart AT-79-54 B are met. 48 FR 3742 51 FR 34772 The agency, under the authority of State law, imposes broader sanctions. TN No. MS-88-1 Supersedes Approval Date Feb 16 1988 Effective Date Jan 1 1988

TN No. MS-87-11 HCFA ID: 1010P/0012P

78a Revision: HCFA-AT-87-14 (BERC) OMB No. 0938-0193 October 1987 4.30 Continued State/Territory: Nebraska Citation 1902(p) of the Act (b) The Medicaid agency meets the requirements of — P.L. 100-93 (secs. 7) (1) Section 1902(p) of the Act by excluding from participation -

(A) At the State's discretion, any individual or entity for any reason for which the Secretary could exclude the individual or entity from participation in a program under Title XVIII in accordance with sections 1128, 1128A, or 1866(b)(2).

42 CFR 438.808 (B) An MCO (as defined in section 1903(m) of

the Act), or an entity furnishing services under a waiver approved under section 1915(b)(1) of the Act, that —

(i) Could be excluded under section

1128(b)(8) relating to owners and managing employees who have been convicted of certain crimes or received other sanctions, or

(ii) Has, directly or indirectly, a substantial

contractual relationship (as defined by the Secretary) with an individual or entity that is described in section 1128(b)(8)(B) of the Act.

1932(d)(1) (2) An MCO, PIHP, PAHP, or PCCM may not have 42 CFR 438.610 prohibited affiliations with individuals (as defined in

42 CFR 438.610(b)) suspended, or otherwise excluded from participating in procurement activities under the Federal Acquisition Regulation or from participating in non-procurement activities under regulations issued under Executive Order No. 12549 or under guidelines implementing Executive Order No. 12549. If the State finds that an MCO, PCCM, PIPH, or PAHP is not in compliance the State will comply with the requirements of 42 CFR 438.610(c).


TN No. MS-88-1

78b Revision: HCFA-AT-87-14 (BERC) OMB No. 0938-0193 October 1987 4.30 Continued State/Territory: Nebraska Citation 1902(a)(39) of the Act (2) Section 1902(a)(39) of the Act by-- P.L. 100-93 (sec 9/5) (A) Excluding an individual or entity from participation for the period specified by the

Secretary, when required by the Secretary to do so in accordance with sections 1128 or 1128A of the Act; and

(B) Providing that no payment will be made with

respect to any item or service furnished by an individual or entity during this period.

(c) The Medicaid agency meets the requirements of-- 1902(a)(41) (1) Section 1902(a)(41) of the Act with respect to of the Act prompt notification to HCFA whenever a provider P.L. 96-272, is terminated, suspended, sanctioned, or (sec. 308(c)) otherwise excluded from participating under this State plan; and 1902(a)(49) of the Act (2) Section 1902(a)(49) of the Act with respect to P.L. 100-93 providing information and access to information (sec. 5(a)(4)) regarding sanctions taken against health care practitioners and providers by State licensing authorities in accordance with section 1921 of the Act. TN No. MS-88-1 Supersedes Approval Date Feb 16 1988 Effective Date Jan 1 1988

TN No. New Page HCFA ID: 1010P/0012P

79 Revision: Region VII OMB No. 0938-0193 December 1989 State/Territory: Nebraska Citation 4.31 Disclosure of Information by Providers and Fiscal Agents 455.103 The Medicaid agency has established procedures for the 44 FR 41644 disclosure of information by providers and fiscal agents as 1902 (a) (38) specified in 42 CFR 455.104 through 455.106. of the Act P.L. 100-93 4.32 Income and Eligibility Verification System (sec. 8(f)) 435.940 The Medicaid agency has established a system for income through 435.960 and eligibility verification in accordance with the 52 FR 5967 requirements of 42CFR 435.940 through 435.960. P.L. 100-360 (Sec. 411(k)(15)) ATTACHMENT 4.32-A describes, in accordance with 42

CFR 435.948(a)(6), the information that will be requested in order to verify eligibility or the correct payment amount and the agencies and the State(s) from which that information will be requested.

TN No. MS-90-9 Supersedes Approval Date Apr 4 1990 Effective Date Jan 1 1987


79a Revision: HCFA-PM-87-14 (BERC) OMB No. 0938-0193 October 1987 State/Territory: Nebraska Citation 4.33 Medicaid Eligibility Cards for Homeless Individuals 1902(a)(48) (a) The Medicaid agency has a method for making cards of the Act, evidencing eligibility for medical assistance available P.L. 99-510 to an individual eligible under the State's approved plan (Section 11005) who does not reside in a permanent dwelling or does P.L 100-93 not have a fixed home or mailing address. (sec. 5(a)(3))

(b) ATTACHMENT 4.33-A specifies the method for issuance of Medicaid eligibility cards to homeless individuals.

TN No. MS-88-1 Supersedes Approval Date Feb 16 1988 Effective Date Jan 1 1988

TN No. MS-87-11 HCFA ID: 1010P/0012P

79b Revision: Region VII OMB No. 0938-0193 December 1989 State/Territory: Nebraska Citation 4.34 Systematic Alien Verification for Entitlements 1137 of The State Medicaid agency has established procedures for the Act the verification of alien status through the Immigration & P.L. 99-603 Naturalization Service (INS) designated system, Systematic (eec. 121) Alien Verification for Entitlements (SAVE), effective P.L. 100-360 October 1, 1988, except for aliens seeking medical (Sec. 411(k)(15)) assistance for treatment of emergency medical conditions under Section 1903(v)(2) of the Social Security Act.

The State Medicaid agency has elected to participate in the option period of October 1, 1987 to September 30, 1988 to verify alien status through the INS designated system (SAVE).

The State Medicaid agency has received the following

type(s) of waiver from participation in SAVE.

Total waiver

Alternative system

Partial implementation TN No. MS-90-9 Supersedes Approval Date Apr 4 1990 Effective Date Jan 1 1987

TN No. MS-88-14 HCFA ID: 1010P/0012P

79c.1 Revision: HCFA-PM-95-4 (HSQB) June 1995 State/Territory: Nebraska Citation 4.35 Enforcement of Compliance for Nursing Facilities 42 CFR (a) Notification of Enforcement Remedies §488.402(f)

When taking an enforcement action against a non- State operated NF, the State provides notification in accordance with 42 CFR 488.402(f). (i) The notice (except for civil money penalties and State monitoring) specifies the:

(1) nature of noncompliance, (2) which remedy is imposed, (3) effective date of the remedy, and (4) right to appeal the determination leading to the remedy.

42 CFR (ii) The notice for civil money penalties is in writing and §488.434 contains the information specified in 42 CFR 488.434. 42 CFR (iii) Except for civil money penalties and State monitoring, notice §488.402(f)(2) is given at least 2 calendar days before the effective date of

the enforcement remedy for immediate jeopardy situations and at least 15 calendar days before the effective date of the enforcement remedy when immediate jeopardy does not exist.

42 CFR (iv) Notification of termination is given to the facility and to the §488.456(c)(d) public at least 2 calendar days before the remedy's effective

date if the noncompliance constitutes immediate jeopardy and at least 15 calendar days before the remedy's effective date if the noncompliance does not constitute immediate jeopardy. The State must terminate the provider agreement of an NF in accordance with procedures in parts 431 and 442.

(b) Factors to be Considered in Selecting Remedies

42 CFR (i) In determining the seriousness of deficiencies, the State §488.488.404(b)(1) considers the factors specified in 42 CFR 488.404(b)(1) & (2).

The State considers additional factors. Attachment 4.35-A

describes the State's other factors.


TN No. MS-90-11

79c.2 Revision: HCFA-PM-95-4 (HSQB) June 1995 State/Territory: Nebraska Citation c) Application of Remedies 42 CFR (i) If there is immediate jeopardy to resident health or safety, §488.410 the State terminates the NF's provider agreement within 23

calendar days from the date of the last survey or immediately imposes temporary management to remove the threat within 23 days.

42 CFR (ii) The State imposes the denial of payment (or its approved §488.417(b) alternative) with respect to any individual admitted to an §1919(h)(2)(C) NF that has not come into substantial compliance of the Act. within 3 months after the last day of the survey. 42 CFR (iii) The State imposes the denial of payment for new §488.414 admissions remedy as specified in §488.417 (or its approved §1919(h)(2)(D) alternative) and a State monitor as specified at §488.422, of the Act. when a facility has been found to have provided substandard

quality of care on the last three consecutive standard surveys.

42 CFR (iv) The State follows the criteria specified at 42 CFR §488.408 §488.408(c)(2), §488.408(d)(2), and §488.408(e)(2), when 1919(h)(2)(A) it imposes remedies in place of or in addition to termination. of the Act. (v) When immediate jeopardy does not exist, the State 42 CFR terminates an NF's provider agreement no later than §488.412(a) 6 months from the finding of noncompliance, if the conditions of 42 CFR 488.412(a) are not met.

(d) Available Remedies 42 CFR (i) The State has established the remedies defined in 42 CFR §488.406(b) 488.406(b). §1919(h)(2)(A) of the Act. (1) Termination (2) Temporary Management (3) Denial of Payment for New Admissions (4) Civil Money Penalties (5) Transfer of Residents; Transfer of Residents with Closure of Facility (6) State Monitoring

Attachments 4.35-B through 4.35-G describe the criteria for applying the above remedies.


TN No. New page

79c.3 Revision: HCFA-PM-95-4 (HSQB) June 1995 State/Territory: Nebraska Citation 42 CFR (ii) The State uses alternative remedies. The §488.406(b) State has established alternative remedies §1919(h)(2)(B)(ii) that the State will impose in place of a of the Act. remedy specified in 42 CFR 488.406(b).

(1) Temporary Management (2) Denial of Payment for New

Admissions (3) Civil Money Penalties (4) Transfer of Residents; Transfer

of Residents with Closure of Facility

(5) State Monitoring.

Attachments 4.35-B through 4.35-G describe the alternative remedies and the criteria for applying them.

42 CFR (e) State Incentive Programs §488.303(b) 1910(h)(2)(F) (1) Public Recognition of the Act. (2) Incentive Payments TN No. MS-95-15 Supersedes Approval Date Oct 23 1995 Effective Date Jul 1 1995

TN No. New Page

79d Revision: HCFA-PM-91-4 (BPD) OMB No. 0938- August 1991 State/Territory: Nebraska Citation 4.36 Required Coordination Between the Medicaid and WIC Programs 1902(a)(11)(C) The Medicaid agency provides for the coordination and 1902(a)(53) between the Medicaid program and the Special of the Act Supplemental Food Program for Women, Infants, and Children (WIC) and provides timely notice and referral to WIC in accordance with section 1902(a)(53) of the Act. TN No. MS-91-24 Supersedes Approval Date Jan 20 1992 Effective Date Nov 1 1991

TN No. New Page

79n Revision: HCFA-PM-91-10 (BPD) December 1991 State/Territory: Nebraska Citation 4.38 Nurse Aide Training and Competency Evaluation for Nursing Facilities 42 CFR 483.75; (a) The State assures that the requirements of 42 CFR 483 Subpart D; 42 CFR 483.150(a),which relate to individuals Secs. 1902(a)(28), deemed to meet the nurse aide training and 1919(e)(1) and (2), competency evaluation requirements, are met. and 1919(f)(2), P.L. 100-203 (Sec. (b) The State waives the competency evaluation 4211(a)(3)); P.L. requirements for individuals who meet the 101-239 (Secs. requirements of 42 CFR 483.150(b)(1). 6901(b)(3) and (4)); P.L. 101-508 (c) The State deems individuals who meet the (Sec. 4801(a)). requirements of 42 CFR 483.150(b)(2) to have

met the nurse aide training and competency evaluation requirements.

(d) The State specifies any nurse aide training and competency evaluation programs it approves as meeting the requirements of 42 CFR 483.152 and competency evaluation programs it approves as meeting the requirements of 42 CFR 483.154.

(e) The State offers a nurse aide training and

competency evaluation program that meets the requirements of 42 CFR 483.152.

(f) The State offers a nurse aide competency

evaluation program that meets the requirements of 42 CFR 483.154


TN No. New Page

79o Revision: HCFA-PM-91-10 (BPD) December 1991 State/Territory: Nebraska Citation 42 CFR 483.75; 42 (g) If the State does not choose to offer a nurse aide CFR 483 Subpart D; training and competency evaluation program or nurse Secs. 1902(a)(28), aide competency evaluation program, the State 1919(e)(1) and (2), reviews all nurse aide training and competency and 1919(f)(2), evaluation programs and competency evaluation P.L. 100-203 (Sec. programs upon request. 4211(a)(3)); P.L. 101-239-(Secs. (h) The State survey agency determines, during the 6901(b)(3) and course of all surveys, whether the requirements of (4)); P.L. 101-508 483.75(e) are met. (Sec. 4801(a)). (i) Before approving a nurse aide training and competency evaluation program, the State determines whether the requirements of 42 CFR 483.152 are met. (j) Before approving a nurse aide competency evaluation program, the State determines whether the requirements of 42 CFR 483.154 are met. (k) For program reviews other than the initial review, the State visits the entity providing the program. (l) The State does not approve a nurse aide training and

competency evaluation program or competency evaluation program offered by or in certain facilities as described in 42 CFR 483.151(b)(2) and (3).


TN No. New Page

79p Revision: HCFA-PM-91-10 (BPD) December 1991 State/Territory: Nebraska Citation 42 CFR 483.75; 42 (m) The State, within 90 days of receiving a request for CFR 483 Subpart D; approval of a nurse aide training and competency Secs. 1902(a)(28), evaluation program or competency evaluation program, 1919(e)(1) and (2), either advises the requestor whether or not the and 1919(f)(2), program has been approved or requests additional P.L. 100-203 (Sec. information from the requestor. 4211(a)(3)); P.L. 101-239 (Secs. (n) The State does not grant approval of a nurse aide 6901(b)(3) and training and competency evaluation program for a (4)); P.L. 101-508 period longer than 2 years. (Sec. 4801(a)). (o) The State reviews programs when notified of substantive changes (e.g., extensive curriculum modification).

(p) The State withdraws approval from nurse aide training and competency evaluation programs and competency evaluation programs when the program is described in 42 CFR483.151(b)(2) or (3).

(q) The State withdraws approval of nurse aide training

and competency evaluation programs that cease to meet the requirements of 42 CFR 483.152 and competency evaluation programs that cease to meet the requirements of 42 CFR 483.154.

(r) The State withdraws approval of nurse aide training

and competency evaluation programs and competency evaluation programs that do not permit unannounced visits by the State.


TN No. New Page

79q Revision: HCFA-PM-91-10 (BPD) December 1991 State/Territory: Nebraska Citation 42 CFR 483.75; 42 (s) When the State withdraws approval from a nurse aide CFR 483 Subpart D; training and competency evaluation program or Secs. 1902(a)(28), competency evaluation program, the State notifies the 1919(e)(1) and (2), program in writing, indicating the reasons for and 1919(f)(2), withdrawal of approval. P.L. 100-203 (Sec. 4211(a)(3)); P.L. (t) The State permits students who have started a training 101-239 (Secs. and competency evaluation program from which 6901(b)(3) and approval is withdrawn to finish the program. (4)); P.L. 101-508 (Sec. 4801(a)). (u) The State provides for the reimbursement of costs incurred in completing a nurse aide training and competency evaluation program or competency evaluation program for nurse aides who become employed by or who obtain an offer of employment from a facility within 12 months of completing such program.

(v) The State provides advance notice that a record of successful completion of competency evaluation will be included in the State's nurse aide registry.

(w) Competency evaluation programs are administered by

the State or by a State-approved entity which is neither a skilled nursing facility participating in Medicare nor a nursing facility participating in Medicaid.

(x) The State permits proctoring of the competency

evaluation in accordance with 42 CFR 483.154(d). (y) The State has a standard for successful completion of

competency evaluation programs. TN No. MS-91-30 Supersedes Approval Date Jan 15 1992 Effective Date Oct 1 1991

TN No. new page

79r “Substitute per letter dated 3/16/99” Revision: HCFA-PM-91-10 (BPD) December 1991 State/Territory: Nebraska Citation 42 CFR 483.75; 42 (z) The State includes a record of successful CFR 483 Subpart D; completion of a competency evaluation within 30 Secs. 1902(a)(28), days of the date an individual is found competent. 1919(e)(1) and (2), and 1919(f)(2), (aa) The State imposes a maximum upon the number P.L. 100-203 (Sec. of times an individual may take a competency 4211(a)(3)); P.L. evaluation program (any maximum imposed is 101-239 (Secs. not less than 3). 6901(b)(3) and (4)); P.L. 101-508 (bb) The State maintains a nurse aide Registry that (Sec. 4801(a)). meets the requirements in 42 CFR 483.156.

(cc) The State includes home health aides on the

registry.

(dd) The State contracts the operation of the registry to a non-State entity.

(ee) ATTACHMENT 4.38 contains the State's

description of registry information to be disclosed in addition to that required in 42 CFR 483.156(c)(1)(iii) and (iv).

(ff) ATTACHMENT 4.38-A contains the State's

description of information included on the registry in addition to the information required by 42 CFR 483.156(c).

P.L. 105-15 (gg) The State waives the prohibition of nurse aide (Sec. 4132.2(e)) training and competency evaluation program

offered in (but not by) certain nursing homes if the State determines the facility meets specified exception criteria.

TN No. MS-99-1 Supersedes Approval Date Mar 30 1999 Effective Date Mar 30 1999

TN No. MS-91-30

79s “Substitute per letter dated 3/16/99” Revision: HCFA-PM-91-10 (BPD) December 1991 State/Territory: Nebraska Citation (hh) The State:

(1) assures there is no other such program offered within a reasonable distance of the facility;

a. the facility must make a diligent effort to locate other

approved NATCEPs within a reasonable distance (1/2 hour travel time each way from the facility) unless the facility can demonstrate distance or program availability would create a hardship for program participants.

b. the facility must provide evidence that classes are not

currently being offered at an approved site within a reasonable distance.

c. the facility must provide evidence that classes are not

currently being offered within a reasonable distance during time frames to meet student and facility needs.

(2) assures, through an oversight effort, an adequate

environment exists for operating the program in the facility; and

a. the facility must be in substantial compliance with the

Federal requirements for participation in §483.13 Resident Behavior and Facility Practices, §483.15 Quality of Life, §483.25 Quality of Care, and §483.75(f) Proficiency of Nurse Aides.

"Substantial compliance" means compliance with the federal requirements of participation as set forth in 42 CFR §§483.13, 483.15, 483.25 and 483.75(f).

b. the facility must not be determined to be a poor

performing facility.

A "poor performing facility" is a facility cited for substandard quality of care on the current standard survey and for substandard quality of care or immediate jeopardy on at least one of the previous two standard surveys. See, Survey and Certification Regional Letter No. 97-02.


TN No. MS-91-30

79t Revision: HCFA-PM-91-10 (BPD) “Substitute per letter dated 3/16/99” December, 1991 State/Territory: Nebraska Citation

c. employees of the facility cannot function as instructors for the program. If the approved NATCEP is experiencing difficulty in finding qualified instructors, the state may, in limited hardship situations, allow the NATCEP to use facility employees to serve as instructors if they meet the qualifications for instructors and the individual is paid and supervised by the NATCEP.

d. the sponsoring NATCEP must describe the

evaluation process used to determine an adequate teaching/learning environment exists for conducting the course (i.e., adequacy of classroom, availability of equipment and oversight of the entire course). The NATCEP is responsible for program administration and assuring program requirements are met.

e. The facility must notify students and the

instructor of their right to register any concerns with the state agency at any time during the course and be given information on how to contact the state agency. The state agency may make unannounced visits to any courses offered to determine compliance with the criteria for the waiver or to investigate complaints.

e. The facility and NATCEP instructor/coordinator

must have policies for communicating and resolving problems encountered during the course.

g. At the end of the course, the NATCEP

instructor/coordinator and all of the students are required to submit an evaluation of the course. The state agency will review and evaluate course evaluations for determination of future waivers.


TN No. MS-91-30

79u Revision: HCFA-PM-91-10 (BPD) “Substitute per letter dated 3/16/99” December, 1991 State/Territory: Nebraska Citation

(3) provides notice of such determination and assurances to the state long term care ombudsman.

a. The state agency will notify the ombudsman

by state agency letter of all facilities granted waivers and oversight efforts to assure compliance with the law.

b. Assurances to the state long term care

ombudsman will include:

• The state agency requires the NATCEP to submit the evaluation process used to determine an adequate teaching/learning environment exists for conducting the course and assuring program requirements are met.

• The state agency requires the NATCEP to

submit the policies developed for communicating and resolving problems encountered during the course.

• The state agency has the right to make

unannounced visits to any courses offered in a facility under waiver. Students or the instructor have the right to register any concerns with the state agency at any time during the program and must be given information on how to contact the agency.


TN No. MS-91-30

79v Revision: HCFA-PM-93-1 (BPD) January, 1993 State/Territory: Nebraska Citation 4.39 Preadmission Screening and Annual Resident Review in Nursing Facilities Secs. 1902(a)(28)(D)(i) (a) The Medicaid agency has in effect a written agreement and 1919(e)(7) with the State mental health and mental retardation of the Act; authorities that meet the requirements of 42 (CFR) P.L. 100-203 431.621(c). (Sec. 4211(c)); P.L. 101-508 (b) The State operates a preadmission and annual (Sec. 4801(b)). resident review program that meets the requirements of 42 CFR 483.100-138.

(c) The State does not claim as "medical assistance under

the State Plan" the cost of services to individuals who should receive preadmission screening or annual resident review until such individuals are screened or reviewed.

(d) With the exception of NF services furnished to certain NF

residents defined in 42 CFR 483.118(c)(1), the State does not claim as "medical assistance under the State plan" the cost of NF services to individuals who are found not to require NF services.

(e) ATTACHMENT 4.39 specifies the State's definition of

specialized services. (f) Except for residents identified in 42 CFR 483.118(c)(1),

the State mental health or mental retardation authority makes categorical determinations that individuals with certain mental conditions or levels of severity of mental illness would normally require specialized services of such an intensity that a specialized services program could not be delivered by the State in most, if not all, NFs and that a more appropriate placement should be utilized.

(g) The State describes any categorical determinations it

applies in ATTACHMENT 4.39A.


TN No. New Page

79w Revision: HCFA-PM-92-3 (HSQB) OMB No.: April, 1992 State/Territory: Nebraska Citation 4.40 Survey & Certification Process Sections 1919(g)(1) (a) The State assures that the requirements of thru (2)and 1919(g)(4) 1919(g)(1)(A)through (C) and section 1919(g)(2)(A) thru (5); of the Act through (E)(iii) of the Act which relate to the survey P.L. 100-203 (Sec. 4212(a)) and certification of non-State owned facilities based on the requirements of section 1919(b), (c) and (d) of the Act, are met. 1919(g)(1)(B) of the Act (b) The State conducts periodic education programs for staff and residents (and their representatives). Attachment 4.40-A describes the survey and certification educational program. 1919(g)(1)(C) of the Act (c) The State provides for a process for the receipt and timely review and investigation of allegations of neglect and abuse and misappropriation of resident property by a nurse aide of a resident in a nursing facility or by another individual used by the facility. Attachment 4.40- B describes the State's process. 1919(g)(1)(C) of the Act (d) The State agency responsible for surveys and certification of nursing facilities or an agency delegated by the State survey agency conducts the process for the receipt and timely review and investigation of allegations of neglect and abuse and misappropriation of resident property. If not the State survey agency, what agency? 1919(g)(1)(C) of the Act (e) The State assures that a nurse aide, found to have neglected or abused a resident or misappropriated resident property in a facility, is notified of the finding. The name and finding is placed on the nurse aide registry. 1919(g)(1)(C) of the Act (f) The State notifies the appropriate licensure authority of any licensed individual found to have neglected or abused a resident or misappropriated resident property in a facility. TN No. MS-92-23 Supersedes Approval Date Mar 4 1993 Effective Date Oct 1 1992

TN No. New Page

79x Revision: HCFA-PM-92-3 (HSQB) OMB No. : April, 1992 State/Territory: Nebraska Citation 1919(g)(2)(A)(i)(I) of the Act (g) The State has procedures, as provided for at

section 1919(g)(2)(A)(i), for the scheduling and conduct of standard surveys to assure that the State has taken all reasonable steps to avoid giving notice through the scheduling procedures and the conduct of the surveys themselves. Attachment 4.40-C describes the State's procedures.

1919(g)(2)(A)(ii) of the Act (h) The State assures that each facility shall have a standard survey which includes (for a case-mix

stratified sample of residents) a survey of the quality of care furnished, as measured by indicators of medical, nursing and rehabilitative care, dietary and nutritional services, activities and social participation, and sanitation, infection control, and the physical environment, written plans of care and audit of resident's assessments, and a review of compliance with resident's rights not later than 15 months after the date of the previous standard survey.

1919(g)(2)(A)(iii)(l) of the Act (i) The State assures that the statewide average interval between standard surveys of nursing facilities does not exceed 12 months.

1919(g)(2)(A)(iii)(II) of the Act (j) The State may conduct a special standard or special abbreviated standard survey within two months of any

change of ownership, administration, management, or director of nursing of the nursing facility to determine whether the change has resulted in any decline in the quality of care furnished in the facility.

1919(g)(2)(B) of the Act (k) The State conducts extended surveys immediately or,

if not practicable, not later than two weeks following a completed standard survey in a nursing facility which is found to have provided substandard care or in any other facility at the Secretary's or State's discretion.


TN No. New Page

79y Revision: HCFA-PM-92-3 (HSQB) OMB No. : April, 1992 State/Territory: Nebraska Citation 1919(g)(2)(C) of the Act (l) The State conducts standard and extended surveys

based upon a protocol, i.e., survey forms, methods, procedures and guidelines developed by HCFA, using individuals in the survey team who meet minimum qualifications established by the Secretary.

1919(g)(2)(D) of the Act (m) The State provides for programs to measure and

reduce inconsistency in the application of survey results among surveyors. Attachment 4.40-D describes the State's programs.

1919(g)(2)(E)(i) of the Act (n) The State uses a multidisciplinary team of professionals including a registered professional nurse. 1919(g)(2)(E)(ii) of the Act (o) The State assures that members of a survey team

do not serve (or have not served within the previous two years) as a member of the staff or consultant to the nursing facility or have no personal or familial financial interest in the facility being surveyed.

1919(g)(2)(E)(iii) of the Act (p) The State assures that no individual shall serve as a

member of any survey team unless the individual has successfully completed a training and test program in survey and certification techniques approved by the Secretary.

1919(g)(4) of the Act (q) The State maintains procedures and adequate staff to

investigate complaints of violations of requirements by nursing facilities and on-site monitoring. Attachment 4.40-E describes the State's complaint procedures.

1919(g)(5)(A) of the Act (r) The State makes available to the public information

respecting surveys and certification of nursing facilities including statements of deficiencies, plans of correction, copies of cost reports, statements of ownership and the information disclosed under section 1126 of the Act.


TN No. New Page

79z Revision: HCFA-PM-92-3 (HSQB) OMB No. : April 1992 State/Territory: Nebraska Citation 1919(g)(5)(B) of the Act (s) The State notifies the State long-term care ombudsman

of the State's finding of noncompliance with any of the requirements of subsection (b), (c), and (d) or of any adverse actions taken against a nursing facility.

1919(g)(5)(C) of the Act (t) If the State finds substandard quality of care in a facility, the State notifies the attending physician of each resident with respect to which such finding is made and the nursing facility administrator licensing board. 1919(g)(5)(D) of the Act (u) The State provides the State Medicaid fraud and abuse agency access to all information concerning survey and certification actions. TN No. MS-92-23 Supersedes Approval Date Mar 4 1993 Effective Date Oct 1 1992

TN No. New Page

79aa Revision: HCFA-AT-80-38 (HSQB) May 22, 1980 State/Territory: Nebraska Citation 4.41 Resident Assessment for Nursing Facilities Sections 1919(b)(3) and (a) The State specifies the instrument to be used by 1919(e)(5); of the Act nursing facilities for conducting a comprehensive, accurate, standardized, reproducible assessment of each resident's functional capacity as required in §1919(b)(3)(A) of the Act. 1919(e)(5)(A) of the Act (b) The State is using: the resident assessment instrument designated by the Health Care Financing Administration (see Transmittal #241 of the State Operations Manual) [§1919(e)(5)(A)]; or 1919(e)(5)(B) of the Act a resident assessment instrument that the

Secretary has approved as being consistent with the minimum data set of core elements, common definitions, and utilization guidelines as specified by the Secretary (see Section 4470 of the State Medicaid Manual for the Secretary's approval criteria) [§1919(e)(5)(B)].


TN No. New Page

Section 6032 State Plan Preprint Page 1 of 3

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State/Territory: Nebraska Citation 4.42 Employee Education About False Claims Recoveries. 1902(a)(68) of (a) The Medicaid agency meets the requirements the Act, regarding establishment of policies and procedures for P.L. 109-171 the education of employees of entities covered by (section 6032) section 1902(a)(68) of the Social Security Act (the Act) regarding false claims recoveries and methodologies for oversight of entities' compliance with these requirements. (1) Definitions.

(A) An "entity" includes a governmental agency, organization, unit, corporation, partnership, or other business arrangement (including any Medicaid managed care organization, irrespective of the form of business structure or arrangement by which it exists), whether for-profit or not-for-profit, which receives or makes payments, under a State Plan approved under title XIX or under any waiver of such plan, totaling at least $5,000,000 annually.

If an entity furnishes items or services at more than a single location or under more than one contractual or other payment arrangement, the provisions of section 1902(a)(68) apply if the aggregate payments to that entity meet the $5,000,000 annual threshold. This applies whether the entity submits claims for payments using one or more provider identification or tax identification numbers.

A governmental component providing Medicaid health care items or services for which Medicaid payments are made would qualify as an "entity" (e.g., a state mental

TN No. 07-02 Supersedes Approval Date May 30 2007 Effective Date Jan 01 2007

TN No. New page


STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State/Territory: Nebraska Citation

health facility or school district providing school-based health services). A government agency which merely administers the Medicaid program, in whole or part (e.g., managing the claims processing system or determining beneficiary eligibility), is not, for these purposes, considered to be an entity.

An entity will have met the $5,000,000 annual threshold as of January 1, 2007, if it received or made payments in that amount in Federal fiscal year 2006. Future determinations regarding an entity's responsibility stemming from the requirements of section 1902(a)(68) will be made by January 1 of each subsequent year, based upon the amount of payments an entity either received or made under the State Plan during the preceding Federal fiscal year.

(B) An "employee" includes any officer or

employee of the entity. (C) A "contractor" or "agent" includes any

contractor, subcontractor, agent, or other person which or who, on behalf of the entity, furnishes, or otherwise authorizes the furnishing of, Medicaid health care items or services, performs billing or coding functions, or is involved in the monitoring of health care provided by the entity.

(2) The entity must establish and disseminate written

policies which must also be adopted by its contractors or agents. Written policies may be on paper or in electronic form, but must be readily available to all employees, contractors, or agents. The entity need not create an employee handbook if none already exists.

TN No. 07-02 Supersedes Approval Date May 30 2007 Effective Date Jan 1 2007

TN No. New Page


STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State/Territory: Nebraska Citation

(3) An entity shall establish written policies for all employees (including management), and of any contractor or agent of the entity, that include detailed information about the False Claims Act and the other provisions named in section 1902(a)(68)(A). The entity shall include in those written policies detailed information about the entity's policies and procedures for detecting and preventing waste, fraud, and abuse. The entity shall also include in any employee handbook a specific discussion of the laws described in the written policies, the rights of employees to be protected as whistleblowers and a specific discussion of the entity's policies and procedures for detecting and preventing fraud, waste, and abuse.

(4) The requirements of this law should be

incorporated into each State's provider enrollment agreements.

(5) The State will implement this State Plan

amendment on January 1, 2007.

(b) ATTACHMENT 4.42-A describes, in accordance with section 1902(a)(68) of the Act, the methodology of compliance oversight and the frequency with which the State will re-assess compliance on an ongoing basis.


TN No. New Page

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State/Territory: Nebraska Citation 4.43 Cooperation with Medicaid Integrity Program Efforts. 1902(a)(69) of The Medicaid agency assures it complies with such the Act, requirements determined by the Secretary to be P.L. 109-171 necessary for carrying out the Medicaid Integrity (section 6034) Program established under section 1936 of the Act. TN No. MS-08-01 Supersedes Approval Date Jun 02 2008 Effective Date Apr 1 2008

TN No. New Page

82

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State/Territory:

Nebraska

Citation

4.44

Medicaid Prohibition on Payments to Institutions or

Entities Located Outside of the United States

1902(a)(80) of _X_the Social Security Act, items or services provided under the State plan or

The State shall not provide any payments for

P.L. 111-148 under a waiver to any financial institution or entity (Section 6505) located outside of the United States. TN No. Supersedes Approval Date

11-05 APR 26 2011 Effective Date

TN No. JUN 01 2011

New Page



4.45 Reserved Citation

TN No. NE 12-08 Supersedes Approval Date OCT 04 2012 Effective Date JAN 01 2012 TN No. New Page

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State/Territory: Nebraska

4.46 Provider Screening and Enrollment (Page 1 of 3)

Citation The State Medicaid agency gives the following assurances: 1902(a)(77) 1902(a)(39) 1902(1c1c); P.L. 111-148 and P.L. 111-152 As per our September 14, 2012, discussion with CMS Regional

Representative Sandra Levels and Michael Berger, Nebraska is assuring compliance as per our previously stated implementation issues related to staffing and systems.

42 CFR 455 PROVIDER SCREENING Subpart E __X__ Assures that the State Medicaid agency complies with the

process for screening providers under section 1902(a)(39), 1902(a)(77) and 1902(1c1c) of the Act.

42 CFR 455.410 ENROLLMENT AND SCREENING OF PROVIDERS __X__ Assures enrolled providers will be screened in accordance with

42 CFR 455.400 et seq.

__X__ Assures that the State Medicaid agency requires all ordering or referring physicians or other professionals to be enrolled under the State plan or under a waiver of the Plan as a participating provider.

42 CFR 455.412 VERIFICATION OF PROVIDER LICENSES __X__ Assures that the State Medicaid agency has a method for verifying providers licensed by a State and that such providers licenses have not expired or have no current limitations.

42 CFR 455.414 REVALIDATION OF ENROLLMENT _ X__ Assures that providers will be revalidated regardless of provider type at least every 5 years.

42 CFR 455.416 TERMINATION OR DENIAL OF ENROLLMENT __X__ Assures that the State Medicaid agency will comply with section 1902(a)(39) of the Act and with the requirements outlined in 42 CFR 455.416 for all terminations or denials of provider enrollment.

42 CFR 455.420 REACTIVATION OF PROVIDER ENROLLMENT __X__ Assures that any reactivation of a provider will include re-screening and payment of application fees as required by 42 CFR 455.460.

________________________________________________________________________ TN No. NE 12-08 Supersedes Approved OCT 04 2012 Effective JAN 01 2012 TN No. New page


(4.46 continued, Page 2 of 3) 42 CFR 455.422 APPEAL RIGHTS

__X__ Assures that all terminated providers and providers denied enrollment as a result of the requirements of 42 CFR 455.416 will have appeal rights available under procedures established by State law or regulation.

42 CFR 455.432 SITE VISITS __X__ Assures that pre-enrollment and post-enrollment site visits of providers who are in "moderate" or "high" risk categories will occur.

42 CFR 455.434 CRIMINAL BACKGROUND CHECKS

__X__ Assures that providers, as a condition of enrollment, will be required to consent to criminal background checks including fingerprints, if required to do so under State law, or by the level of screening based on risk of fraud, waste or abuse for that category of provider.

FEDERAL DATABASE CHECKS

42 CFR 455.436 __X__ Assures that the State Medicaid agency will perform Federal database checks on all providers or any person with an ownership or controlling interest or who is an agent or managing employee of the provider. NATIONAL PROVIDER IDENTIFIER

42 CFR 455.440 __X__ Assures that the State Medicaid agency requires the National Provider Identifier of any ordering or referring physician or other professional to be specified on any claim for payment that is based on an order or referral of the physician or other professional. SCREENING LEVELS FOR MEDICAID PROVIDERS

42 CFR 455.450 __X__ Assures that the State Medicaid agency complies with 1902(a)(77) and 1902(kk) of the Act and with the requirements outlined in 42 CFR 455.450 for screening levels based upon the categorical risk level determined for a provider.

APPLICATION FEE

42 CFR 455.460 __X__ Assures that the State Medicaid agency complies with the requirements for collection of the application fee set forth in section 1866(j)(2)(C) of the Act and 42 CFR 455.460.

_________________________________________________________________________ TN No. NE 12-08 Supersedes Approved OCT 04 2012 Effective JAN 01 2012 TN No. New page


(4.46 continued, Page 3 of 3)

TEMPORARY MORATORIUM ON ENROLLMENT OF NEW

42 CFR 455.470 PROVIDERS OR SUPPLIERS __X__ Assures that the State Medicaid agency complies with any temporary moratorium on the enrollment of new providers or provider types imposed by the Secretary under section 1866(j)(7) and 1902(a)(4) of the Act, subject to any determination by the State and written notice to the Secretary that such a temporary moratorium would not adversely impact beneficiaries' access to medical assistance.

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1151. The time required to complete this information collection is estimated to average 15 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. ____________________________________________________________________________ TN No. NE 12-08 Supersedes Approved OCT 04 2012 Effective JAN 01 2012 TN No. New page

80 Revision: HCFA-AT-80-38 (BPP) May 22, 1980 State/Territory: Nebraska

SECTION 5: PERSONAL ADMINISTRATION Citation 5.1 Standards of Personnel Administration 42 CFR 432.10 (a) (a) The Medicaid agency has established and will AT-78-90 maintain methods of personnel administration AT-79-23 in conformity with standards prescribed by the U.S. AT-80-34 Civil Service Commission in accordance with Section 208of the Intergovernmental Personnel Act of 1970 and the regulations on Administration of the Standards for a Merit System of Personnel Administration, 5 CFR Part 900,Subpart F. All requirements of 42 CFR 432.10 are met. The plan is locally administered and State- supervised. The requirements of 42 CFR 432.10 with respect to local agency administration are met. (b) Affirmative Action Plan The Medicaid agency has in effect an affirmative action plan for equal employment opportunity that includes specific action steps and timetables and meets all other requirements of 5 CFR Part 900, Subpart F. TN No. MS-77-4 Supersedes Approval Date Effective Date Oct 15 1977

TN No. MS-76-1

81 Revision: HCFA-AT-80-38 (BPP) May 22, 1980 State/Territory: Nebraska Citation 5.2 Reserved TN No. MS-80-38 Supersedes Approval Date Effective Date

TN No

82 Revision: HCFA-AT-80-38 (BPP) May 22, 1980 State/Territory: Nebraska Citation 5.3 Training Programs; Subprofessional and Volunteer Programs 42 CFR Part 432, The Medicaid agency meets the requirements of 42 CFR Subpart B Part 432, Subpart B, with respect to a training program AT-78-90 for agency personnel and the training and use of subprofessional staff and volunteers. TN No. MS-78-3 Supersedes Approval Date Mar 27 1978 Effective Date Jan 1 1978

TN No. MS-77-4

83 Revision: HCFA-AT-80-38 (BPP) May 22, 1980 State/Territory: Nebraska

SECTION 6 FINANCIAL ADMINISTRATION Citation 6.1 Fiscal Policies and Accountability 42 CFR 433.32 The Medicaid agency and, where applicable, local AT-79-29 agencies administering the plan, maintains an accounting system and supporting fiscal records adequate to assure that claims for Federal funds are in accord with applicable Federal requirements. The requirements of 42 CFR 433.32 are met. TN No. MS-76-8 Supersedes Approval Date Aug 6 1976 Effective Date Jun 30 1976

TN No. MS-74-1

84 Revision: HCFA-AT-81 (BPP) State/Territory: Nebraska Citation 6.2 Cost Allocation 42 CFR 433.34 There is an approved cost allocation plan on file with the 47 FR 17490 Department in accordance with the requirements contained in 45 CFR Part 95, Subpart E. TN No. MS-87-12 Supersedes Approval Date Aug 26 1982 Effective Date May 24 1982

TN No. MS-76-8

85 Revision: HCFA-AT-80-38 (BPP) May 22, 1980 State/Territory: Nebraska Citation 6.3 State Financial Participation 42 CFR 433.33 (a) State funds are used in both assistance and AT-79-29 administration. AT-80-34 State funds are used to pay all of the non-Federal stare of total expenditures under the plan.

There is local participation. State funds are to pay not less than 40 percent of the non-Federal share of the total expenditures under the plan. There is a method of apportioning Federal and State funds among the political subdivisions of the State or an equalization or other basis which, assures that lack of adequate funds from local sources will not result in lowering the amount, duration, scope or quality of care and services or level of administration under the plan in any part of the State.

(b) State and Federal funds are apportioned among the

political subdivisions of the State on a basis consistent with equitable treatment of individuals in similar circumstances throughout the State.

TN No. MS-87-8 Supersedes Approval Date Jun 1987 Effective Date Jul 1 1986

TN No. MS-76-8

86 Revision: HCFA-PM-91-4 (BPD) OMB No. 0938- August 1991 State/Territory: Nebraska

SECTION 7: GENERAL PROVISIONS Citation 7.1 Plan Amendments 42 CFR 430.12(c) The plan will be amended whenever necessary to reflect

new or revised Federal statutes or regulations or material change in State law, organization, policy or State agency operation.


TN No. MS-74-1

87 Revision: HCFA-PM-91-4 (BPD) OMB No. 0938- August 1991 State/Territory: Nebraska Citation 7.2 Nondiscrimination 45 CFR Parts In accordance with title VI of the Civil Rights Act of 1964 80 and 84 (42 U.S.C. 2000d et. seq.), Section 504 of the

Rehabilitation Act of 1973 (29 U.S.C. 70b), and the regulations at 45 CFR Parts 80 and 84, the Medicaid agency assures that no individual shall be subject to discrimination under this plan on the grounds of race, color, national origin, or handicap.

The Medicaid agency has methods of administration to assure that each program or activity for which it receives Federal financial assistance will be operated in accordance with title VI regulations. These methods for title VI are described in ATTACHMENT 7.2-A.


TN No. MS-79-4

88 Revision: HCFA-PM-91-4 (BPD) OMB No. 0938- August 1991 State/Territory: Nebraska Citation 7.3 [Reserved] TN No. MS-92-7 Supersedes Approval Date Aug 7 1992 Effective Date Apr 1 1992


Revision: HCFA PM-91-4 (BPD) OMB No.: 0938- August 1991

State/Territory: Nebraska Citation 7.4 State Governor's Review 42 CFR 430.12(b) The Medicaid agency will provide opportunity for the Office

of the Governor to review State plan amendments, long range program planning projections, and other periodic reports thereon, excluding periodic, statistical, budget and fiscal reports. Any comments made will be transmitted to the Health Care Financing Administration with such documents.

Not applicable. The Governor -

Does not wish to review any plan material.

Wishes to review only the plan material specified

in the enclosed document. I hereby certify that I am authorized to submit this plan on behalf of

Nebraska Department of Health and Human Services (Designated Single State Agency)


TN No. MS-00-07

State/Territory: Nebraska Section 7.4 page 90

TN: NE 20-0010 Approval Date: 4/24/20 Supersedes TN: NEW Effective Date: 3/1/20

Section 7 – General Provisions 7.4. Medicaid Disaster Relief for the COVID-19 National Emergency

On March 13, 2020, the President of the United States issued a proclamation that the COVID-19 outbreak in the United States constitutes a national emergency by the authorities vested in him by the Constitution and the laws of the United States, including sections 201 and 301 of the National Emergencies Act (50 U.S.C. 1601 et seq.), and consistent with section 1135 of the Social Security Act (Act). On March 13, 2020, pursuant to section 1135(b) of the Act, the Secretary of the United States Department of Health and Human Services invoked his authority to waive or modify certain requirements of titles XVIII, XIX, and XXI of the Act as a result of the consequences COVID-19 pandemic, to the extent necessary, as determined by the Centers for Medicare & Medicaid Services (CMS), to ensure that sufficient health care items and services are available to meet the needs of individuals enrolled in the respective programs and to ensure that health care providers that furnish such items and services in good faith, but are unable to comply with one or more of such requirements as a result of the COVID-19 pandemic, may be reimbursed for such items and services and exempted from sanctions for such noncompliance, absent any determination of fraud or abuse. This authority took effect as of 6PM Eastern Standard Time on March 15, 2020, with a retroactive effective date of March 1, 2020. The emergency period will terminate, and waivers will no longer be available, upon termination of the public health emergency, including any extensions. The State Medicaid agency (agency) seeks to implement the policies and procedures described below, which are different than the policies and procedures otherwise applied under the Medicaid state plan, during the period of the Presidential and Secretarial emergency declarations related to the COVID-19 outbreak (or any renewals thereof), or for any shorter period described below: Describe shorter period here.

NOTE: States may not elect a period longer than the Presidential or Secretarial emergency declaration (or any renewal thereof). States may not propose changes on this template that restrict or limit payment, services, or eligibility, or otherwise burden beneficiaries and providers.

Request for Waivers under Section 1135

_X____ The agency seeks the following under section 1135(b)(1)(C) and/or section 1135(b)(5) of the Act:

a. __X___ SPA submission requirements – the agency requests modification of the requirement to submit the SPA by March 31, 2020, to obtain a SPA effective date during the first calendar quarter of 2020, pursuant to 42 CFR 430.20.

b. __X__ Public notice requirements – the agency requests waiver of public notice requirements that would otherwise be applicable to this SPA submission. These requirements may include those specified in 42 CFR 440.386 (Alternative Benefit Plans), 42 CFR 447.57(c) (premiums and cost sharing), and 42 CFR 447.205 (public notice of changes in statewide methods and standards for setting payment rates).



c. __X___ Tribal consultation requirements – the agency requests modification of tribal consultation timelines specified in Nebraska Medicaid state plan, as described below:

Nebraska will begin the tribal consultation period concurrently with submission of this SPA to CMS. Nebraska tribes will have 15 calendar days to initiate a tribal consultation in which Nebraska will immediately address any questions.

Section A – Eligibility

1. _____ The agency furnishes medical assistance to the following optional groups of individuals described in section 1902(a)(10)(A)(ii) or 1902(a)(10)(c) of the Act. This may include the new optional group described at section 1902(a)(10)(A)(ii)(XXIII) and 1902(ss) of the Act providing coverage for uninsured individuals. Include name of the optional eligibility group and applicable income and resource standard.

2. _____ The agency furnishes medical assistance to the following populations of individuals described in section 1902(a)(10)(A)(ii)(XX) of the Act and 42 CFR 435.218:

a. _____ All individuals who are described in section 1905(a)(10)(A)(ii)(XX)

Income standard: _____________ -or-

b. _____ Individuals described in the following categorical populations in section 1905(a) of the Act: Income standard: _____________

3. _____ The agency applies less restrictive financial methodologies to individuals excepted from

financial methodologies based on modified adjusted gross income (MAGI) as follows. Less restrictive income methodologies:



Less restrictive resource methodologies:

4. __X___ The agency considers individuals who are evacuated from the state, who leave the state for medical reasons related to the disaster or public health emergency, or who are otherwise absent from the state due to the disaster or public health emergency and who intend to return to the state, to continue to be residents of the state under 42 CFR 435.403(j)(3).

5. _____ The agency provides Medicaid coverage to the following individuals living in the state,

who are non-residents:

6. __X___ The agency provides for an extension of the reasonable opportunity period for non-citizens declaring to be in a satisfactory immigration status, if the non-citizen is making a good faith effort to resolve any inconsistences or obtain any necessary documentation, or the agency is unable to complete the verification process within the 90-day reasonable opportunity period due to the disaster or public health emergency.

Section B – Enrollment

1. _____ The agency elects to allow hospitals to make presumptive eligibility determinations for the following additional state plan populations, or for populations in an approved section 1115 demonstration, in accordance with section 1902(a)(47)(B) of the Act and 42 CFR 435.1110, provided that the agency has determined that the hospital is capable of making such determinations.

Please describe the applicable eligibility groups/populations and any changes to reasonable limitations, performance standards or other factors.

2. _____ The agency designates itself as a qualified entity for purposes of making presumptive

eligibility determinations described below in accordance with sections 1920, 1920A, 1920B, and 1920C of the Act and 42 CFR Part 435 Subpart L. Please describe any limitations related to the populations included or the number of allowable PE periods.



3. __X___ The agency designates the following entities as qualified entities for purposes of making presumptive eligibility determinations or adds additional populations as described below in accordance with sections 1920, 1920A, 1920B, and 1920C of the Act and 42 CFR Part 435 Subpart L. Indicate if any designated entities are permitted to make presumptive eligibility determinations only for specified populations. The agency designates entities qualified to make determinations for pregnant women only, as defined in NE 13-0027, to expand to provide determinations for Parent/Caretaker Relatives, Former Foster Care Children, and Children under age 19. The policies and procedures for qualified entities applies to these determinations. There may be no more than one period of presumptive eligibility per pregnancy. Periods of presumptive eligibility are limited to no more than one period within two calendar years for Parent/Caretaker Relatives, Former Foster Care Children, and Children under age 19.

4. _____ The agency adopts a total of _____ months (not to exceed 12 months) continuous

eligibility for children under age enter age _____ (not to exceed age 19) regardless of changes in circumstances in accordance with section 1902(e)(12) of the Act and 42 CFR 435.926.

5. _____ The agency conducts redeterminations of eligibility for individuals excepted from MAGI-

based financial methodologies under 42 CFR 435.603(j) once every _____ months (not to exceed 12 months) in accordance with 42 CFR 435.916(b).

6. _____ The agency uses the following simplified application(s) to support enrollment in affected

areas or for affected individuals (a copy of the simplified application(s) has been submitted to CMS).

a. _____ The agency uses a simplified paper application.

b. _____ The agency uses a simplified online application.

c. _____ The simplified paper or online application is made available for use in call-centers or other telephone applications in affected areas.

Section C – Premiums and Cost Sharing

1. _____ The agency suspends deductibles, copayments, coinsurance, and other cost sharing charges as follows: Please describe whether the state suspends all cost sharing or suspends only specified deductibles, copayments, coinsurance, or other cost sharing charges for specified items and services or for specified eligibility groups consistent with 42 CFR 447.52(d) or for specified income levels consistent with 42 CFR 447.52(g).

2. _____ The agency suspends enrollment fees, premiums and similar charges for:

a. _____ All beneficiaries



b. _____ The following eligibility groups or categorical populations:

Please list the applicable eligibility groups or populations.

3. _____ The agency allows waiver of payment of the enrollment fee, premiums and similar charges for undue hardship. Please specify the standard(s) and/or criteria that the state will use to determine undue hardship.

Section D – Benefits

Benefits:

1. _____ The agency adds the following optional benefits in its state plan (include service descriptions, provider qualifications, and limitations on amount, duration or scope of the benefit):

2. _____ The agency makes the following adjustments to benefits currently covered in the state plan:

3. _____ The agency assures that newly added benefits or adjustments to benefits comply with all

applicable statutory requirements, including the statewideness requirements found at 1902(a)(1), comparability requirements found at 1902(a)(10)(B), and free choice of provider requirements found at 1902(a)(23).

4. _____ Application to Alternative Benefit Plans (ABP). The state adheres to all ABP provisions in

42 CFR Part 440, Subpart C. This section only applies to states that have an approved ABP(s).

a. _____ The agency assures that these newly added and/or adjusted benefits will be made available to individuals receiving services under ABPs.

b. _____ Individuals receiving services under ABPs will not receive these newly added and/or adjusted benefits, or will only receive the following subset: Please describe.



Telehealth:

5. __X___ The agency utilizes telehealth in the following manner, which may be different than outlined in the state’s approved state plan: Nebraska Medicaid is offering reimbursement for telephonic evaluation and management for the following beneficiaries seeking care when they are already an established patient or the parent or legal guardian of an established patient: -Beneficiaries who are actively experiencing mild symptoms of COVID-19 (fever, cough, shortness of breath) prior to going to the emergency department, urgent care, or other health care facility; -Beneficiaries who need routine, uncomplicated follow up and who are not currently experiencing symptoms of COVID-19; and, -Beneficiaries requiring behavioral health assessment and management. The telephonic evaluation and management services must be rendered by a qualified health care professional, defined as a physician, nurse practitioner, or physician assistant actively enrolled in Nebraska Medicaid at the time of service. Telephonic evaluation and management by staff other than those listed should not be submitted for reimbursement and will not be reimbursed. Services are to be rendered only to established patients, and parents or legal guardians of established patients. Telephonic evaluation and management of services may be utilized by the following behavioral health providers: Psychologist (PhD/PsyD), provisional psychologist (PHD provisional), licensed independent mental health worker (LIHMP), licensed mental health worker (LHMP), provisionally licensed mental health worker (PLMHP), licensed alcohol and drug counselor (LADC), and provisionally licensed alcohol and drug counselor (PLADC). Home Health: Initial assessments and recertification assessments may be completed by using telehealth for physicians and nurse practitioners. Initial assessments, recertifications, and ongoing visits per individual plan of care may be completed by using telehealth for nurses. Telehealth may be used for supervisory visits for aide services. Hospice: Initial assessments and recertification assessments may be completed by using telehealth for the appropriate physicians and nurse practitioners. Initial assessments, recertifications, and ongoing visits per individual plan of care may be completed by using telehealth for nurses. Lactation Counseling Services provided through EPSDT: Comprehensive lactation counseling services may be provided by using telehealth. Tobacco Cessation Counseling: Tobacco Cessation Counseling services may be provided by using telehealth. Pediatric Feeding Disorder Outpatient Therapy: Pediatric Feeding Disorder Outpatient Therapy services may be provided by using telehealth.



Community Support: Community Support Services may be done via telehealth. As clinically appropriate, HIPPA compliant two-way real-time interactive audio and video telehealth may be offered to proceed with behavioral health interventions. All visits, regardless of modality of communication, must be clinically necessary to work on treatment goals as outlined in the beneficiaries plan of care. Visit documentation must include the modality of communication, the rationale for that modality and the duration of the intervention.

Drug Benefit:

6. _____ The agency makes the following adjustments to the day supply or quantity limit for covered outpatient drugs. The agency should only make this modification if its current state plan pages have limits on the amount of medication dispensed.

Please describe the change in days or quantities that are allowed for the emergency period and for which drugs.

7. _____ Prior authorization for medications is expanded by automatic renewal without clinical

review, or time/quantity extensions.

8. _____ The agency makes the following payment adjustment to the professional dispensing fee when additional costs are incurred by the providers for delivery. States will need to supply documentation to justify the additional fees.

Please describe the manner in which professional dispensing fees are adjusted.

9. _____ The agency makes exceptions to their published Preferred Drug List if drug shortages

occur. This would include options for covering a brand name drug product that is a multi-source drug if a generic drug option is not available.

Section E – Payments

Optional benefits described in Section D:

1. _____ Newly added benefits described in Section D are paid using the following methodology:

a. _____ Published fee schedules –

Effective date (enter date of change): _____________

Location (list published location): _____________



b. _____ Other: Describe methodology here.

Increases to state plan payment methodologies:

2. _____ The agency increases payment rates for the following services: Please list all that apply.

a. _____ Payment increases are targeted based on the following criteria: Please describe criteria.

b. Payments are increased through:

i. _____ A supplemental payment or add-on within applicable upper payment limits:

Please describe.

ii. _____ An increase to rates as described below.

Rates are increased:

_____ Uniformly by the following percentage: _____________ _____ Through a modification to published fee schedules –

Effective date (enter date of change): _____________ Location (list published location): _____________

_____ Up to the Medicare payments for equivalent services. _____ By the following factors:

Please describe.



Payment for services delivered via telehealth:

3. __X___ For the duration of the emergency, the state authorizes payments for telehealth services that:

a. __X___ Are not otherwise paid under the Medicaid state plan;

b. _____ Differ from payments for the same services when provided face to face;

c. __X___ Differ from current state plan provisions governing reimbursement for telehealth;

Indian Health Services, Tribal Clinics, and Urban Indian Health Centers (ITU’s) may bill the encounter rate for telehealth services that would typically have been bill for a non-telehealth encounter. In order to remain in accordance with the four walls rule in federal statute, ITU’s may bill encounters via telehealth the same as they would typically bill for a non-telehealth encounter, with the addition of the telehealth modifier to both the encounter and the corresponding procedure codes, as long as either the provider or the client is within the walls of the facility during the time of the visit. Federally Qualified Health Centers and Rural Health Centers may bill the encounter rate for core services provided via telehealth during the emergency period. The changes to telehealth described in section D. 5. make use of new rates and new separate billing codes. Code G2012 is used for a brief communication technology-based service; for example, virtual or telephone communication by a physician or other qualified health care professional who can report evaluation and management services, provided to an established patient, not originating from a related E/M service provided within the previous 7 days or not leading to an E/M service or procedure within the next 24 hours or soonest available appointment; 5-10 minutes of medical discussion. The rate for this code is $13.82. Code 99441 is used for telephone evaluation and management service by a physician, nurse practitioner, or physician assistant who may report evaluation and management (E/M) services provided to an established patient, parent, or guardian not originating from a related E/M service provided within the previous 7 days or leading to an E/M service or procedure within the next 24 hours or soonest available appointment; 5-10 minutes of medical discussion. The rate for this code is $14.47. Code 99442 is used for telephone evaluation and management service by a physician, nurse practitioner, or physician assistant who may report E/M services provided to an established patient, parent, or guardian not originating from a related E/M service provided within the previous 7 days or leading to an E/M service or procedure within the next 24 hours or soonest available appointment; 11-20 minutes of medical discussion. The rate for this code is $28.71.



Code 99443 is used for telephone evaluation and management service by a physician, nurse practitioner, or physician assistant who may report E/M services provided to an established patient, parent, or guardian not originating from a related E/M service provided within the previous 7 days or leading to an E/M service or procedure within the next 24 hours or soonest available appointment; 21-30 minutes of medical discussion. The rate for this code is $46.60. Code 98966 is used for Telephone assessment and management service provided by an enrolled behavioral health provider to an established patient, parent, or guardian not originating from a related assessment and management service provided within the previous 7 days not leading to an assessment and management service or procedure with the next 24 hours or soonest available appointment; 5-10 minutes of medical discussion. The rate for this code is $11.75. Code 98967 is used for telephone assessment and management service provided by an enrolled behavioral health provider to an established patient, parent, or guardian not originating from a related assessment and management service provided within the previous 7 days not leading to an assessment and management service or procedure with the next 24 hours or soonest available appointment; 11-20 minutes of medical discussion. The rate for this code is $20.67. Code 98968 is used for telephone assessment and management service provided by an enrolled behavioral health provider to an established patient, parent, or guardian not originating from a related assessment and management service provided within the previous 7 days not leading to an assessment and management service or procedure with the next 24 hours or soonest available appointment; 21-30 minutes of medical discussion. The rate for this code is $32.42. Code G0071 is used for Payment for communication technology-based services for 5 minutes or more of a virtual (not face-to-face) communication between an FQHC or RHC practitioner and a FQHC or RHC patient. The rate for this code is $46.40.

d. _____ Include payment for ancillary costs associated with the delivery of covered services via telehealth, (if applicable), as follows:

i. _____ Ancillary cost associated with the originating site for telehealth is incorporated into fee-for-service rates.

ii. _____ Ancillary cost associated with the originating site for telehealth is separately reimbursed as an administrative cost by the state when a Medicaid service is delivered.

Other:

4. __X__ Other payment changes:

Nebraska Medicaid is also adding new codes and rates associated with COVID-19 that do not appear currently on our fee schedule. These codes and rates are:



U0001 Test Price - $35.92 U0002 Test Price - $51.31 87635 - $51.33

Section F – Post-Eligibility Treatment of Income

1. _____ The state elects to modify the basic personal needs allowance for institutionalized individuals. The basic personal needs allowance is equal to one of the following amounts:

a. _____ The individual’s total income

b. _____ 300 percent of the SSI federal benefit rate

c. _____ Other reasonable amount: _________________

2. _____ The state elects a new variance to the basic personal needs allowance. (Note: Election of this option is not dependent on a state electing the option described the option in F.1. above.)

The state protects amounts exceeding the basic personal needs allowance for individuals who have the following greater personal needs:

Please describe the group or groups of individuals with greater needs and the amount(s) protected for each group or groups.

Section G – Other Policies and Procedures Differing from Approved Medicaid State Plan /Additional Information

PRA Disclosure Statement

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148 (Expires 03/31/2021). The time required to complete this information collection is estimated to average 1 to 2 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. Your response is required to receive a waiver under Section 1135 of the Social Security Act. All responses are public and will be made available on the CMS web site. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05,



Baltimore, Maryland 21244-1850. ***CMS Disclosure*** Please do not send applications, claims, payments, medical records or any documents containing sensitive information to the PRA Reports Clearance Office. Please note that any correspondence not pertaining to the information collection burden approved under the associated OMB control number listed on this form will not be reviewed, forwarded, or retained. If you have questions or concerns regarding where to submit your documents, please contact the Centers for Medicaid & CHIP Services at 410-786-3870.

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